What is the best management approach for an adult patient with no significant medical history presenting with lower back pain?

Best Management for Lower Back Pain

For an adult with lower back pain and no red flags, begin immediately with staying active (avoiding bed rest), applying superficial heat, and using NSAIDs as first-line medication, while stratifying risk at 2 weeks with the STarT Back tool to direct appropriate intensity of nonpharmacologic interventions. 1, 2

Initial Assessment and Red Flag Screening

Screen urgently for red flags requiring immediate imaging or specialist referral:

• Progressive neurologic deficits, cauda equina symptoms (bowel/bladder dysfunction, saddle anesthesia), or severe motor weakness 3, 1
• History of cancer, unexplained weight loss, fever suggesting infection, or significant trauma 1
• Night pain that is constant and unrelenting, or abnormal neurologic examination findings 3

If red flags are present: Obtain immediate MRI (superior to CT for soft tissue visualization) and arrange urgent specialist consultation within 2 weeks 3, 1

If no red flags: Do not order routine imaging, as it does not improve outcomes and findings are often nonspecific 1, 2

Immediate First-Line Management (All Patients)

Activity modification:

• Advise patients to remain active and continue ordinary activities within pain limits—this accelerates recovery compared to bed rest 1, 2
• Avoid bed rest entirely, as it causes deconditioning and muscle atrophy 2
• Provide reassurance about favorable prognosis, with 90% of acute episodes resolving within 6 weeks 2

Nonpharmacologic interventions:

• Apply superficial heat (heating pads) for 20-30 minutes, 3-4 times daily—this provides moderate pain relief superior to acetaminophen or ibuprofen in the first 1-2 days 4, 1, 2
• Consider spinal manipulation if administered by appropriately trained providers, which provides small to moderate short-term benefits 4, 2

Pharmacologic treatment (if patient requests medication):

• Start with NSAIDs (e.g., naproxen, ibuprofen) as first-line—these have the strongest evidence for moderate, clinically meaningful pain relief 3, 1
• Use acetaminophen (up to 3000-4000mg daily) as an alternative if NSAIDs are contraindicated, though evidence is slightly weaker 3, 2
• Avoid systemic corticosteroids (no benefit over placebo), benzodiazepines (high sedation rates), and opioids initially (abuse potential without superior efficacy) 1, 2

Risk Stratification at 2 Weeks (STarT Back Tool)

Apply the STarT Back tool at 2 weeks to predict risk of developing persistent disabling pain: 4, 3, 1

Low-risk patients:

• Encourage self-management with evidence-based educational materials, online resources, and telephone helplines 3
• Continue activity and heat application as needed 1

Medium-risk patients:

• Refer to physiotherapy for patient-centered management plan with personalized, supervised exercise programs incorporating stretching and strengthening 3, 1
• Consider adding massage, acupuncture, or continued spinal manipulation 1, 2

High-risk patients (anxiety, depression, catastrophizing, fear-avoidance beliefs, job dissatisfaction):

• Refer for comprehensive biopsychosocial assessment by physiotherapy with skills to address psychological factors 4, 3
• Consider low-intensity psychological therapy (cognitive behavioral therapy, mindfulness-based stress reduction) delivered by a single professional 4, 1

Management of Persistent Pain (4-12 Weeks)

If symptoms persist beyond 4-6 weeks without improvement:

• Continue NSAIDs or acetaminophen if providing benefit 1, 2
• Intensify nonpharmacologic therapies: exercise therapy (cornerstone of treatment), cognitive behavioral therapy, acupuncture, yoga, tai chi, or massage 4, 1, 2
• Consider plain radiography only if patient has not improved with conservative therapy and has risk factors for vertebral compression fracture 1
• Refer for intensive interdisciplinary rehabilitation combining physical, psychological, and educational interventions 2

Chronic Low Back Pain Management (>12 Weeks)

Nonpharmacologic treatments remain first-line: 4, 1, 2

• Exercise therapy (moderate-quality evidence, moderate efficacy)—should be cornerstone of treatment 4, 2
• Multidisciplinary rehabilitation (moderate-quality evidence) 4, 2
• Cognitive behavioral therapy (low to moderate-quality evidence) 4, 2
• Acupuncture, mindfulness-based stress reduction, tai chi, yoga (low to moderate-quality evidence) 4, 2
• Spinal manipulation (low-quality evidence for chronic pain) 4, 2

Pharmacologic escalation if inadequate response to nonpharmacologic therapy:

• Continue NSAIDs as first-line if effective 1, 2
• Add tramadol or duloxetine as second-line options 1, 2
• Consider tricyclic antidepressants or SNRIs as part of multimodal strategy 4, 2
• Reserve opioids as absolute last resort with careful monitoring and strategy for managing side effects and compliance 4, 1, 2

Timing for Specialist Referral

Refer urgently (within 2 weeks) if:

• Pain is disabling or motor/sensory deficits are present 3
• Red flags emerge at any point 3, 1

Refer no later than 3 months if:

• Symptoms persist despite comprehensive conservative management 3
• Pain severity increases or functional disability worsens 3
• No response to standard noninvasive therapies after 3 months minimum 1

Critical Pitfalls to Avoid

• Never prescribe bed rest—staying active is superior for recovery 3, 1, 2
• Avoid "physical therapy for all" approach—use stratified care based on STarT Back tool to direct resources appropriately 4, 3
• Do not routinely image uncomplicated acute low back pain—this exposes patients to unnecessary radiation without clinical benefit 1, 2
• Avoid overreliance on opioids—they lack superior efficacy and carry significant abuse potential 1, 2
• Do not use systemic corticosteroids—good evidence demonstrates no benefit over placebo 1, 2