Management of Back Pain in Healthy Adults
For a healthy adult with back pain and no red flags, advise immediate reactivation while avoiding bed rest, start NSAIDs like ibuprofen 400mg every 4-6 hours, and use the STarT Back tool at 2 weeks to stratify care—reserving physiotherapy for medium-risk patients and biopsychosocial assessment for high-risk patients only. 1
Initial Assessment and Red Flag Screening
First, rule out emergencies and serious pathology by screening for red flags:
- Progressive motor or sensory loss, new urinary retention or incontinence (cauda equina syndrome) 2
- History of cancer, recent spinal procedure, or significant trauma 2
- Nighttime pain, constant pain, fever, or unexplained weight loss 3
- Age under 18 or over 50 with new-onset pain 4
If any red flags are present, obtain imaging immediately and refer urgently. 2 Otherwise, imaging provides no clinical benefit and increases healthcare utilization unnecessarily. 5
Immediate Management (First 2 Weeks)
Advise reactivation and explicitly tell patients to avoid bed rest—this represents a fundamental shift from outdated recommendations and is critical for recovery. 1, 6
Pharmacologic Treatment
Start with ibuprofen 400mg every 4-6 hours (maximum 3200mg daily), using the lowest effective dose for the shortest duration. 7 Doses above 400mg show no additional benefit for acute pain. 7 Before prescribing, assess cardiovascular and gastrointestinal risk factors, as NSAIDs increase risk of bleeding, ulcers, and cardiovascular events. 7
If NSAIDs are contraindicated, acetaminophen is a reasonable alternative though provides slightly weaker analgesia. 6, 8
Self-Management Education
Provide comprehensive self-care resources beyond simple leaflets—this is where most patients report inadequate support. 1 Direct patients to:
- Online audio resources and educational materials 1
- Telephone helplines for back pain support 1
- Evidence-based information on staying active 5
Critical pitfall: Signposting alone is insufficient. Patients need direct support, reinforcement, and frequent contact from primary care during this period. 1
Risk Stratification at 2 Weeks
Use the STarT Back tool at 2 weeks to predict risk of developing persistent disabling pain. 1, 5 This evidence-based decision tool prevents the ineffective "physical therapy for all" approach and directs resources appropriately. 1, 6
Low-Risk Patients
Encourage continued self-management with ongoing access to educational resources and supportive contact. 1, 5, 6 These patients should not receive routine physiotherapy referrals. 1
Medium-Risk Patients
Refer to physiotherapy for a patient-centered management plan with personalized, supervised exercise programs incorporating stretching and strengthening. 1, 5, 6 Exercise therapy shows moderate effectiveness for chronic low back pain. 5
High-Risk Patients
Refer for comprehensive biopsychosocial assessment within a multidisciplinary team context. 1, 5 These patients require intensive intervention including:
- High-intensity cognitive behavioral therapy 1
- Intensive interdisciplinary rehabilitation 5
- Complex medication management if needed (including consideration of gabapentin for neuropathic features) 5
Review Timeline and Escalation
Review all patients no later than 12 weeks from onset. 1 If no improvement or deterioration occurs:
- Consider referral to specialist pain center or specialist spinal center 1
- Minimum time from presentation to specialist referral should be 14 weeks for uncomplicated cases 1
For severe or disabling pain with neurological deficits, refer within 2 weeks—earlier intervention may prevent surgery. 1, 6
Additional Non-Pharmacologic Options for Chronic Pain
If pain persists beyond 12 weeks, therapies with moderate effectiveness include:
- Acupuncture, massage therapy, spinal manipulation 5
- Yoga (strong evidence for short-term and moderate evidence for long-term effectiveness) 2
- Cognitive behavioral therapy 1, 5
Avoid routine use of: muscle relaxants (limited evidence), systemic corticosteroids (no benefit over placebo), long-term opioids (insufficient evidence for chronic use), or epidural injections for non-radicular pain. 5, 4
Key Pitfalls to Avoid
- Never prescribe bed rest—staying active is superior for recovery 1, 6
- Don't order routine imaging without red flags—it leads to overtreatment without clinical benefit 5, 4
- Avoid "physical therapy for all"—use stratified care based on STarT Back results 1, 6
- Don't rely on passive education alone—patients need active support and frequent contact 1
- Remember most back pain resolves within 4-6 weeks with conservative management 3, 4