Management of Low Back Pain in Adults
Initial Assessment and Red Flag Identification
Begin with nonpharmacologic therapy for acute/subacute low back pain and reserve imaging only for red flags or persistent symptoms beyond 4-6 weeks. 1
Conduct a focused history and physical examination specifically looking for:
- Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) requiring immediate MRI and neurosurgical consultation 2
- Cancer history with unexplained weight loss suggesting metastatic disease 2
- Fever with midline tenderness indicating possible vertebral osteomyelitis 2
- Significant trauma or osteoporosis/chronic steroid use suggesting compression fracture 2
- Progressive neurologic deficits requiring urgent imaging 2, 3
Perform neurological examination including straight leg raise test to evaluate for radiculopathy. 2
Avoid routine imaging for nonspecific low back pain without red flags, as it exposes patients to unnecessary radiation without clinical benefit and findings are often nonspecific. 2, 3, 4
Acute and Subacute Low Back Pain (<12 weeks)
First-Line Nonpharmacologic Treatment
Prioritize nonpharmacologic interventions as primary therapy, as most acute low back pain improves over time regardless of treatment. 1
- Superficial heat (heating pads, heat wraps) provides moderate pain relief and disability reduction (moderate-quality evidence) 1, 2
- Massage therapy reduces pain and improves function (low-quality evidence) 1
- Acupuncture decreases pain intensity (low-quality evidence) 1
- Spinal manipulation improves pain and function (low-quality evidence) 1, 2
Advise patients to stay active and avoid bed rest, as maintaining activity reduces disability and improves outcomes while bed rest leads to deconditioning. 2, 3, 4
Pharmacologic Treatment (If Nonpharmacologic Insufficient)
Add medications only if patients specifically desire pharmacologic treatment: 1
- NSAIDs (naproxen, ibuprofen) as first-line pharmacologic option (moderate-quality evidence) 1, 2
- Skeletal muscle relaxants as alternative first-line option (moderate-quality evidence) 1
- Acetaminophen (up to 3000-4000 mg/day) for mild-to-moderate pain, though slightly less effective than NSAIDs 2, 3
Avoid opioids including tramadol for acute pain due to abuse potential and lack of superior efficacy. 2
Chronic Low Back Pain (>12 weeks)
First-Line Nonpharmacologic Treatment
Begin with exercise therapy as the cornerstone of treatment, combined with other evidence-based nonpharmacologic interventions. 1, 3, 4
Strong evidence supports (moderate-quality evidence): 1, 4
- Exercise therapy (specific type matters less than adherence)
- Multidisciplinary rehabilitation (combining physical, psychological, and educational interventions)
- Acupuncture
- Mindfulness-based stress reduction
Low-quality but supportive evidence for: 1, 4
- Tai chi
- Yoga (particularly Iyengar yoga)
- Motor control exercise (targeting spinal-supporting muscles)
- Cognitive behavioral therapy (especially when psychosocial factors present)
- Spinal manipulation
- Progressive relaxation
- Low-level laser therapy
Combining heat with exercise provides greater pain relief than exercise alone. 4
Pharmacologic Escalation for Inadequate Response
Use a stepwise approach when nonpharmacologic therapy provides insufficient relief: 1, 3
First-line: NSAIDs (moderate-quality evidence) 1, 3
- Tramadol
- Duloxetine (30 mg daily, titrating to 60 mg daily)
- Opioids only after documented failure of all other therapies, with careful risk assessment including screening for substance use disorder, mental health conditions, and concurrent sedative use, and only when potential benefits clearly outweigh risks
Risk Stratification and Psychosocial Factors
Use the STarT Back tool at 2 weeks to identify patients at risk for chronic disabling pain. 2
Identify yellow flags predicting chronicity: 2, 5
- Depression and anxiety
- Catastrophizing and fear-avoidance beliefs
- Job dissatisfaction
- Passive coping strategies
For high-risk patients, refer for comprehensive biopsychosocial assessment and consider psychological interventions if psychosocial factors are prominent. 2
Interventions to Strongly Avoid
Do NOT use the following interventions as they lack evidence of benefit: 3, 4
- Epidural injections (local anesthetic, steroids, or combination)
- Radiofrequency ablation of facet joints
- Joint-targeted injections (local anesthetic or steroids)
- Intramuscular injections of local anesthetic
- TENS (shows no difference compared to sham)
- Lumbar supports (no clear benefits demonstrated)
- Prolonged bed rest (worsens outcomes through deconditioning)
Follow-up and Reassessment
Reevaluate at 1 month if symptoms persist without improvement. 2
Consider earlier reassessment for: 2
- Patients over 65 years
- Signs of radiculopathy or spinal stenosis
- Worsening symptoms
If symptoms persist beyond 4-6 weeks despite conservative management: 2
- Consider plain radiography as initial imaging option
- Refer for physical therapy or intensive rehabilitation
- Reassess for psychosocial barriers to recovery
Specialist Referral Indications
Refer when: 3
- No response to standard noninvasive therapies after 3 months minimum
- Progressive neurologic deficits
- Persistent functional disabilities despite comprehensive conservative therapy
- Red flags requiring urgent intervention
Immediate imaging and specialist consultation required for: 2, 3
- Cauda equina syndrome
- Progressive neurological deficits
- Suspected infection or malignancy
Expected Outcomes
Set realistic expectations: The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate, with effects on function generally smaller than effects on pain. 4 Up to one-third of patients report persistent moderate pain at 1 year after an acute episode. 1