What can a patient do for lower back stiffness in a primary care setting?

Management of Lower Back Stiffness in Primary Care

For lower back stiffness, patients should stay active and avoid bed rest, use NSAIDs for pain relief, and engage in self-management strategies with early reassessment at 2 weeks to determine if escalation of care is needed. 1

Initial Management (First 2 Weeks)

Immediate Actions

• Advise reactivation and explicitly avoid bed rest – staying active is superior to rest for back pain outcomes 1
• Provide NSAIDs as first-line pain medication – ibuprofen 400-800mg is the initial medication of choice for musculoskeletal back pain 2
• Initiate patient education and self-management resources including online materials, telephone helplines, and written information 1
• Rule out red flags requiring urgent evaluation: progressive neurological deficits, bowel/bladder dysfunction, motor deficits at multiple levels, or cauda equina syndrome 1, 3

Self-Care Strategies

Patients need more than simple advice – they require direct support, reinforcement, and frequent contact from primary care 1. Self-management resources should include:

• Online audio resources and literature 1
• Access to specialist healthcare charities working in pain management 1
• Paper-based educational materials 1

Critical pitfall: Simply signposting to advice is insufficient; back pain has significant impact on work and lifestyle, requiring active primary care support 1.

Risk Stratification at 2 Weeks

Use the STarT Back tool at 2 weeks from pain onset to predict risk of developing persistent disabling pain and guide resource allocation 1, 4.

Low-Risk Patients

• Encourage continued self-management with supportive follow-up 1
• Continue activity modification and NSAIDs as needed 1

Medium-Risk Patients

• Refer to physiotherapy for a patient-centered management plan 1
• Implement supervised exercise programs incorporating stretching and strengthening 5

High-Risk Patients

• Refer for comprehensive biopsychosocial assessment within a multidisciplinary team context 1, 5
• Consider intensive interdisciplinary rehabilitation for chronic symptoms 5

Escalation Timeline

At 6-12 Weeks Without Improvement

• Review no later than 12 weeks from onset 1
• Consider referral to specialist pain center or specialist spinal center if no improvement 1
• Implement high-intensity cognitive behavioral therapy for persistent pain 1, 5
• Consider complex medication management including neuropathic pain medications if appropriate 1, 5

When to Refer to Specialists

Refer to orthopedic specialists for structural abnormalities, mechanical features, or failed conservative management after 3-12 months 4. Refer to neurologists for progressive neurological deficits, radiculopathy, or neuropathic pain not responding to first-line treatments 4.

Medication Approach

• NSAIDs are first-line – ibuprofen demonstrates rapid absorption with peak levels at 1-2 hours and is comparable to aspirin for pain control with fewer gastrointestinal side effects 2
• Avoid routine opioids – if used, employ lowest dose possible, shortest duration, and close monitoring 3
• Simple analgesics like paracetamol have limited evidence for nonspecific low back pain 6

Common Pitfalls to Avoid

• Never recommend bed rest – this is outdated advice that worsens outcomes 1, 7
• Avoid routine imaging in the absence of red flags – imaging abnormalities are common in asymptomatic patients and lead to unnecessary interventions 1, 3, 4, 6
• Don't delay assessment of psychosocial factors – these are stronger predictors of outcomes than physical findings 1, 4, 6
• Avoid "physical therapy for all" approach – use stratified care to direct resources appropriately 1, 5
• Don't provide passive treatments exclusively – active treatments are more effective for improving function and return to work 7

Evidence Strength Note

The British Pain Society guidelines 1 represent the most comprehensive and recent approach to primary care management of low back pain, emphasizing stratified care using the STarT Back tool. This approach is supported by the American College of Physicians 1 for diagnostic triage and the consistent finding across multiple guidelines 6 that staying active, avoiding bed rest, and using NSAIDs form the cornerstone of initial management.