What are the initial management options for patients with low back pain?

Initial Management of Low Back Pain

For acute or subacute low back pain, start with nonpharmacologic treatment using superficial heat, massage, acupuncture, or spinal manipulation, and only add NSAIDs or skeletal muscle relaxants if pharmacologic treatment is specifically desired. 1

Classification by Duration

Low back pain management depends critically on symptom duration:

• Acute: Less than 4 weeks 1
• Subacute: 4 to 12 weeks 1
• Chronic: More than 12 weeks 1

Most acute low back pain is self-limited and improves regardless of treatment, though up to one-third of patients report persistent moderate pain at 1 year. 1

Initial Assessment Requirements

Conduct a focused history and physical examination specifically to identify red flags requiring immediate imaging or specialist referral: 2

• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction)
• History of cancer
• Unexplained weight loss
• Fever suggesting infection
• Significant trauma
• History of osteoporosis or chronic steroid use
• Progressive neurologic deficits

Perform neurological examination including straight leg raise test to evaluate for radiculopathy. 2 Midline tenderness may indicate vertebral compression fracture or infection if accompanied by fever. 2

First-Line Treatment Algorithm

For Acute/Subacute Low Back Pain (< 12 weeks)

Nonpharmacologic treatments (choose one or more): 1

• Superficial heat (moderate-quality evidence) 1
• Massage (low-quality evidence) 1
• Acupuncture (low-quality evidence) 1
• Spinal manipulation (low-quality evidence) 1

If pharmacologic treatment is desired: 1

• NSAIDs (moderate-quality evidence) - superior pain relief but carry GI, renal, and cardiovascular risks 1, 3
• Skeletal muscle relaxants (moderate-quality evidence) - such as cyclobenzaprine, tizanidine, or metaxalone for short-term use 1, 3
• Acetaminophen (up to 4g/day) - more favorable safety profile but slightly weaker analgesic 3

Critical patient instructions: 3

• Remain active with flexion-based activities rather than bed rest
• Provide evidence-based reassurance about favorable natural course
• Advise returning to normal activities as tolerated

For Chronic Low Back Pain (> 12 weeks)

Initial nonpharmacologic treatment (choose one or more): 1

• Exercise therapy (moderate-quality evidence) - programs with individual tailoring, supervision, stretching, and strengthening show best outcomes 1, 3
• Multidisciplinary rehabilitation (moderate-quality evidence) 1
• Acupuncture (moderate-quality evidence) 1
• Mindfulness-based stress reduction (moderate-quality evidence) 1
• Tai chi (low-quality evidence) 1
• Yoga (low-quality evidence) 1
• Cognitive behavioral therapy (low-quality evidence) 1
• Spinal manipulation (low-quality evidence) 1

If inadequate response to nonpharmacologic therapy: 1

• First-line pharmacologic: NSAIDs 1
• Second-line pharmacologic: Tramadol or duloxetine 1
• Last resort: Opioids only after failure of above treatments, and only if potential benefits outweigh risks after discussion of known risks and realistic benefits 1

Imaging Guidelines

Avoid routine imaging for nonspecific low back pain without red flags. 3, 2 Routine imaging provides no clinical benefit, leads to increased healthcare utilization without improving outcomes, and exposes patients to unnecessary radiation. 3, 2

Order MRI lumbar spine (preferred) or CT only if: 3, 2

• Symptoms persist or progress despite 6 weeks of optimal conservative management
• Severe or progressive neurologic deficits develop
• Red flags emerge suggesting serious underlying pathology (cancer, infection, cauda equina)

When to Escalate Care

Consider referral or consultation when: 1

• No response to standard noninvasive therapies after 3 months minimum 1
• Progressive neurologic deficits despite conservative management 3
• Persistent functional disabilities and pain despite comprehensive conservative therapy 3

For subacute pain (4-8 weeks), consider intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention), which is moderately effective. 1

Critical Pitfalls to Avoid

• Never prescribe prolonged bed rest - causes deconditioning and worsens disability 3, 2
• Never order routine imaging without red flags - increases costs without improving outcomes 3, 2
• Never use systemic corticosteroids - not more effective than placebo for spinal stenosis 3
• Never rely on imaging findings alone - many MRI abnormalities appear in asymptomatic individuals 3
• Never prescribe opioids as first-line therapy - reserve only for patients who have failed all other treatments 1
• Never attribute symptoms to "normal aging" without proper assessment - may delay recognition of progressive neurologic compromise 3

Additional Considerations for Radicular Symptoms

If radicular symptoms develop: 3

• Gabapentin provides small, short-term benefits for radiculopathy 3
• Tricyclic antidepressants may provide pain relief for neuropathic pain components 3
• Consider epidural steroid injections only after failure of conservative management and if imaging confirms nerve root compression 3