What are the next steps for a 23-year-old with chronic lower back pain and normal lumbosacral x-ray, potentially related to work activities?

Management of Chronic Work-Related Low Back Pain in a 23-Year-Old with Normal X-Ray

For this 23-year-old with chronic work-related back pain and normal imaging, the next step is to apply the STarT Back tool within 2 weeks to stratify risk for persistent disability, then initiate nonpharmacologic treatment with exercise therapy, advise continued activity modification at work, and provide reassurance about the favorable prognosis. 1

Immediate Risk Stratification

• Apply the STarT Back tool at 2 weeks from initial presentation to identify whether this patient is at low, medium, or high risk for developing persistent disabling pain 1
• This evidence-based decision support tool directs resources appropriately and has established cost-effectiveness 1
• Low-risk patients should self-manage, medium-risk patients require physiotherapy with a patient-centered plan, and high-risk patients need physiotherapy with comprehensive biopsychosocial assessment 1

First-Line Nonpharmacologic Treatment

Nonpharmacologic interventions are the primary treatment for chronic low back pain (>12 weeks duration), not medications. 1

• Exercise therapy is the overwhelming element of treatment and should be initiated regardless of risk stratification 1, 2
• Additional effective options include spinal manipulation, acupuncture, massage, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, or cognitive behavioral therapy 1
• Approximately 80% of patients with work-related overuse injuries recover within 3-6 months with conservative management 3

Activity and Work Modifications

• Advise the patient to remain active and avoid bed rest, as staying active is more effective than rest for chronic low back pain 1
• Consider a "fit note" (statement of fitness for work) that provides specific guidance on work capacity rather than complete work cessation 1
• The workplace can play an important role in recovery, though evidence is insufficient to guide specific recommendations about modified work duties 1
• Physical demands of lifting heavy objects should be addressed, but complete work avoidance is counterproductive 1

Patient Education and Self-Management

• Inform the patient about the generally favorable prognosis - most chronic low back pain improves substantially with conservative management 1
• Provide evidence-based self-care education resources, as these are inexpensive and nearly as effective as costlier interventions like supervised exercise or acupuncture 1
• Explain that the normal x-ray is reassuring and that imaging rarely identifies a precise cause for nonspecific low back pain 1
• Direct support, reinforcement, and frequent contact from primary care are usually needed, as signposting alone is often insufficient 1

Pharmacologic Treatment (Second-Line Only)

Medications should only be considered if nonpharmacologic therapy is inadequate. 1

• NSAIDs are first-line pharmacologic therapy if medication is desired, with tramadol or duloxetine as second-line options 1
• Acetaminophen is slightly weaker than NSAIDs but reasonable as initial medication due to better safety profile 1
• Opioids should only be considered after failure of all other treatments and only if benefits outweigh risks for this individual patient 1

When to Reassess or Refer

• Review progress no later than 12 weeks after initiating treatment 1
• If no improvement or deterioration occurs, consider referral to a specialist pain center or specialist spinal center 1
• Biopsychosocial assessment by a multidisciplinary team is indicated for high-risk patients identified by the STarT Back tool 1
• Routine advanced imaging (MRI) is not indicated unless red flags develop, neurologic deficits appear, or pain fails to respond to conservative therapy 4

Critical Pitfalls to Avoid

• Do not order MRI or other advanced imaging at this stage - the x-ray is sufficient and further imaging does not improve outcomes in nonspecific low back pain 1, 4
• Do not prescribe opioids as initial therapy - they should be reserved only for patients who fail all other treatments 1
• Do not recommend bed rest or complete work cessation - both worsen outcomes compared to remaining active 1
• Do not assume this will resolve spontaneously - one-third of patients report persistent moderate pain at 1 year, making active intervention important 1