What is the recommended management system for back pain?

Management System for Back Pain

Use a stratified, stepped-care approach based on pain duration and risk stratification, starting with reassurance, activity advice, and NSAIDs, then escalating to multimodal therapy for patients who fail initial management.

Initial Assessment and Risk Stratification

Perform diagnostic triage to classify patients into one of four categories: nonspecific low back pain, pain with radiculopathy/spinal stenosis, pain from non-spinal source, or pain with specific spinal pathology 1, 2.

Red Flags Requiring Immediate Action

• Progressive motor or sensory loss, new urinary retention or overflow incontinence 2, 3
• Cauda equina syndrome (requires immediate MRI and surgical consultation) 2, 4
• History of cancer, unexplained weight loss, fever, or significant trauma relative to age 2, 3
• Recent invasive spinal procedure 3

Risk Stratification Tool

Use the STarT Back tool to stratify patients into low-risk versus high-risk categories for persistent disability 5. This determines treatment intensity and need for biopsychosocial intervention.

Imaging Guidelines

Avoid routine imaging for nonspecific low back pain, even with midline tenderness 1, 2.

• Order MRI or CT only when: severe/progressive neurologic deficits present, serious underlying conditions suspected, or persistent symptoms beyond 4-6 weeks in surgical candidates 1, 2
• Plain radiography is appropriate only for suspected vertebral compression fracture or after 4-6 weeks of failed conservative management 2, 6
• Negative plain films do not rule out disease 4

Treatment Algorithm by Pain Duration

Acute Low Back Pain (<4 weeks)

First-Line Approach:

• Reassure patients that 90% of episodes resolve within 6 weeks regardless of treatment 4
• Advise staying active, avoiding bed rest, and continuing ordinary activities within pain limits 1, 4
• Provide self-care education materials based on evidence-based guidelines 1

Pharmacologic Management:

• NSAIDs or acetaminophen as first-line medications 5, 1, 7
• NSAIDs provide superior pain relief but carry gastrointestinal and cardiovascular risks 7, 2
• Acetaminophen (up to 3000-4000mg/day) has more favorable safety profile but slightly weaker efficacy 7, 2
• Skeletal muscle relaxants (excluding baclofen) for short-term use if NSAIDs/acetaminophen inadequate 5, 7
• Tizanidine is well-studied; all muscle relaxants cause sedation 7
• Avoid systemic corticosteroids (no greater efficacy than placebo) 5, 1

Non-Pharmacologic Options:

• Superficial heat application (good evidence for moderate benefit) 1
• Spinal manipulation (fair evidence for small to moderate benefit) 1
• McKenzie exercises for pain radiating below the knee 4

Review within 2 weeks from onset 5. If no improvement or deterioration, proceed to subacute management.

Subacute Low Back Pain (4-12 weeks)

Continue effective first-line approaches and add:

• Intensive interdisciplinary rehabilitation or functional restoration with cognitive-behavioral components 1
• Goal-directed manual physical therapy (not passive modalities like heat, traction, ultrasound, or TENS) 4
• Review no later than 12 weeks 5

For high-risk patients on STarT Back:

• Refer for biopsychosocial assessment performed in context of multidisciplinary team 5
• If no improvement, consider referral to specialist pain center or specialist spinal center 5

Chronic Low Back Pain (>12 weeks)

Non-Pharmacologic Therapies (Primary Recommendations):

• Exercise therapy (cornerstone of treatment with good evidence of moderate efficacy) 5, 1
• Cognitive-behavioral therapy (good evidence of moderate efficacy) 5, 1
• Spinal manipulation (moderate effectiveness for pain relief and functional improvement) 1
• Acupuncture, massage therapy, yoga (proven benefits) 1
• Intensive interdisciplinary rehabilitation combining physical, psychological, and educational interventions 1

Pharmacologic Management:

• Continue NSAIDs or acetaminophen if effective 1
• Tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (SNRIs) as part of multimodal strategy 5, 1
• Tricyclic antidepressants have small to moderate benefit (effect size 0.5-0.8) 5
• Duloxetine has evidence of benefit; other antidepressants lack evidence 3
• Gabapentin for radicular symptoms 5, 1
• Opioids or tramadol only for severe, disabling pain not controlled with acetaminophen and NSAIDs 5, 2

Specialist Management:

• Biopsychosocial assessment in multidisciplinary team context 5
• Complex medication management including opioids and neuropathic pain medications 5
• High-intensity cognitive behavioral therapy 5
• Consider referral to specialist spinal surgical service for refractory cases 5

Special Populations and Considerations

Radiculopathy/Radicular Pain

• Gabapentin provides small, short-term benefits for radicular symptoms 1, 7
• Consider epidural steroid injections for persistent radicular symptoms beyond 4 weeks (mixed evidence) 6
• Avoid continuous or intermittent traction (no demonstrated effectiveness) 1
• Consider MRI and specialist referral if symptoms persist beyond 4 weeks despite conservative management 1

Psychosocial Factors

• Screen and treat depression appropriately as it commonly coexists with chronic back pain 1
• Assess yellow flags (psychosocial risk factors predicting chronic disability) to tailor education and advice 5, 2
• Incorporate cognitive-behavioral components for patients at high risk of persistent disability 5, 1

Common Pitfalls to Avoid

• Overuse of imaging: findings on MRI/CT are often nonspecific and do not improve outcomes 1, 2
• Overreliance on opioids without considering multimodal alternatives 5, 2
• Prescribing benzodiazepines (risks of abuse, addiction, tolerance) 7
• Using baclofen for non-spastic back pain (little evidence; indicated only for spasticity) 7
• Advising bed rest instead of staying active 1, 4
• Referring for passive physical therapy modalities (heat, ultrasound, TENS) rather than active exercise 4
• Referring for surgery in absence of red flags or after inadequate trial of conservative management 4

Monitoring and Follow-Up

• Establish monitoring strategy for side effects, adverse effects, and compliance before prescribing long-term pharmacologic therapy 5
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs; use lowest effective doses for shortest periods 7
• Reevaluate patients with persistent, unimproved symptoms after 1 month 2
• Consider earlier reassessment for older patients, those with radiculopathy/spinal stenosis, or worsening symptoms 2
• Magnitude of pain benefits from most therapies is typically small to moderate and short-term 1