What are the treatment options for lumbar (low back) pain and what are the associated red flags?

From the Guidelines

Treatment for low back pain should begin with conservative measures, including rest, over-the-counter pain medications, and physical therapy, while being vigilant for red flags that necessitate immediate medical attention, as recommended by the American College of Physicians and the American Pain Society 1.

Key Considerations

• Conservative measures, such as rest for 24-48 hours, over-the-counter pain medications like acetaminophen or NSAIDs, and physical therapy focusing on core strengthening exercises and stretching, should be initiated first.
• Red flags, including severe trauma, fever above 100.4°F, unexplained weight loss, history of cancer, progressive neurological deficits, pain that worsens when lying down or at night, and pain unresponsive to treatment after 6 weeks, should be identified and addressed promptly.
• Imaging studies, such as MRI or CT, should be considered for patients who have failed 6 weeks of conservative therapy or have red flags, as recommended by the American College of Radiology 1.

Non-Pharmacologic Interventions

• Physical therapy, including core strengthening exercises and stretching, should be initiated after acute pain subsides.
• Heat therapy, for 15-20 minutes several times daily, can help relax muscles, while ice packs may reduce inflammation in the first 48-72 hours.
• Patients should gradually return to normal activities while avoiding movements that exacerbate pain.

Pharmacologic Interventions

• Over-the-counter pain medications, such as acetaminophen or NSAIDs, should be used for 1-2 weeks.
• Prescription medications, such as muscle relaxants, may be considered for persistent pain.

Red Flags

• Severe trauma, fever above 100.4°F, unexplained weight loss, history of cancer, progressive neurological deficits, pain that worsens when lying down or at night, and pain unresponsive to treatment after 6 weeks, should be identified and addressed promptly, as they may indicate serious underlying conditions such as infection, malignancy, cauda equina syndrome, or vertebral fracture requiring urgent evaluation with appropriate imaging and specialist referral 1.

From the Research

Low Back Pain Treatment

• The treatment of low back pain typically involves a combination of non-pharmacologic and pharmacologic interventions 2.
• Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 2.
• Pharmacologic interventions are second-line treatment, with nonsteroidal anti-inflammatory drugs being the initial medication of choice 2, 3, 4.
• Duloxetine may also be beneficial for the treatment of chronic low back pain 2.

Red Flags

• Red flags are indicators of serious conditions that warrant immediate intervention, and include symptoms such as radicular pain, neuromuscular deficits, and recent trauma 2, 4.
• Patients with low back pain should have a history and physical examination to identify red flags and yellow flags (i.e., psychological, environmental, and social factors) that indicate risk of disability 2.
• Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy 2, 4.

Treatment of Acute and Chronic Low Back Pain

• For acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods 3, 4.
• For chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions 2, 4.
• Referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks 4.

Evidence for Treatment Methods

• There is evidence to support the use of various treatment methods for low back pain, including general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures 5.
• However, the evidence for some treatment methods is limited, and more research is needed to determine their effectiveness 6, 5.