What is the initial management approach for a patient presenting with lower back pain?

Initial Management of Lower Back Pain

Advise immediate reactivation while avoiding bed rest, provide appropriate pain relief with NSAIDs as first-line medication, and implement comprehensive self-management education with a plan to reassess within 2 weeks using the STarT Back tool for risk stratification. 1

Immediate First Steps (Day 1)

Rule Out Red Flags

• Screen for serious pathology requiring urgent intervention: progressive neurological deficits, cauda equina symptoms (saddle anesthesia, bowel/bladder dysfunction), night pain, constant unremitting pain, fever, unexplained weight loss, history of cancer, or abnormal neurologic examination 2, 3
• If red flags present, obtain imaging immediately and consider urgent specialist referral within 2 weeks 2, 3
• If no red flags, imaging is not indicated at initial presentation 3, 4

Activity Modification

• Explicitly advise patients to stay active and continue ordinary activities within pain limits 1, 3
• Strongly counsel against bed rest, which worsens outcomes and increases disability 1, 2, 3
• Reassure that 90% of acute episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur 3

Pain Management

• Start NSAIDs (such as naproxen) as first-line pharmacologic therapy, using the lowest effective dose for shortest duration 2, 3
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 2
• Acetaminophen is a reasonable alternative if NSAIDs are contraindicated, though provides slightly weaker analgesia 2, 3
• COX-2 inhibitors, muscle relaxants, and opiates have not demonstrated superiority over NSAIDs for acute low back pain 3

Patient Education and Self-Management

• Provide comprehensive self-management resources beyond simple leaflets: online audio resources, telephone helplines, paper-based information, and links to specialist healthcare charities 1
• Direct support, reinforcement, and frequent contact from primary care are essential—signposting alone is insufficient 1
• Discuss proper body mechanics and safe back exercises for injury prevention 3
• Consider ice for painful areas and gentle stretching exercises 3

Two-Week Reassessment and Risk Stratification

Use STarT Back Tool

• At 2 weeks from pain onset, apply the STarT Back tool to predict risk of developing persistent disabling pain 1, 2
• This evidence-based, cost-effective tool stratifies patients into low, medium, or high risk categories 1

Management Based on Risk Level

Low-Risk Patients:

• Encourage continued self-management with comprehensive resources 1, 2, 5
• Continue supportive management in primary care 1
• Avoid unnecessary treatments and referrals 1

Medium-Risk Patients:

• Refer to physiotherapy for patient-centered management plan 1, 2, 5
• Implement personalized, supervised exercise programs incorporating stretching and strengthening 2
• Consider McKenzie exercises, particularly helpful for pain radiating below the knee 3

High-Risk Patients:

• Refer for comprehensive biopsychosocial assessment within multidisciplinary team context 1, 5
• Review no later than 12 weeks from onset 1
• Consider fit notes (statements of fitness for work) to manage return to work if patient is absent 1

When Conservative Management Fails

Timing for Specialist Referral

• If no improvement or deterioration at 2-week review, escalate care according to risk stratification 1
• Consider imaging after 6 weeks if no improvement, though not routinely required 3
• Refer to specialist pain center or specialist spinal center if no improvement by 12 weeks 1, 2
• Earlier urgent referral (within 2 weeks) if pain is severely disabling or motor/sensory deficits develop 2

Advanced Interventions for Persistent Pain

• High-intensity cognitive behavioral therapy for patients not responding to standard approaches 1, 5
• Complex medication management including consideration of neuropathic pain medications 1, 5
• Individualized stepped management approach within multidisciplinary team 1

Critical Pitfalls to Avoid

• Never recommend bed rest—this is outdated advice that increases disability 1, 2, 3
• Avoid "physical therapy for all" approach—use stratified care to direct resources appropriately based on risk level 1, 2
• Do not order routine imaging in absence of red flags, as it provides no clinical benefit and increases healthcare utilization 4
• Do not rely on passive treatments—active treatments are more effective for improving function and return to work 6
• Remember that keeping active despite low back pain is the core "healthy" message supported by best evidence 6