What is the most appropriate next step in management for a patient with acute back pain after physical activity, no prior back problems, and unremarkable past medical history?

Management of Acute Back Pain After Physical Activity

Osteopathic manipulative treatment (OMT) is the most appropriate next step for this patient with acute mechanical back pain, no red flags, and identified somatic dysfunction. 1

Clinical Context and Rationale

This patient presents with classic acute mechanical low back pain following overhead activity (painting a ceiling), with:

• No neurologic deficits 2, 3
• Negative straight-leg raise (ruling out radiculopathy) 4
• Identified somatic dysfunction (tissue texture abnormalities and motion restriction) 2
• No red flags requiring imaging or urgent intervention 2, 3, 4

Why Osteopathic Manipulative Treatment is Preferred

Spinal manipulation is specifically recommended by the American College of Physicians as a cornerstone treatment for acute low back pain. 1 The CDC 2022 guidelines explicitly state that spinal manipulation is effective for acute back pain with radiculopathy, and even more so for uncomplicated mechanical back pain. 1

• The patient has documented somatic dysfunction with specific motion restrictions that are directly amenable to OMT 2
• Spinal manipulation provides short-term pain relief and functional improvement in acute low back pain 1, 5
• This approach addresses the identified structural abnormalities without medication risks 1

Why Other Options Are Less Appropriate

Bed Rest (Option A)

Bed rest should be avoided as it leads to deconditioning and worse outcomes. 2, 3, 6, 7, 8

• A landmark randomized trial demonstrated that patients continuing ordinary activities recovered faster than those prescribed bed rest 8
• The American College of Physicians explicitly recommends advising patients to remain active rather than resting in bed 2, 3, 6
• Recovery was slowest among patients assigned to bed rest in controlled trials 8

Muscle Relaxants (Option B)

While muscle relaxants can be used for acute low back pain, they are not first-line when effective nonpharmacologic options are available. 1, 7

• The American College of Physicians recommends nonpharmacologic approaches as the cornerstone of treatment before medications 1, 2
• Muscle relaxants have not been shown to be more effective than NSAIDs for acute low back pain 7
• This patient has no contraindications to OMT, making it the preferred initial approach 1

Radiography (Option D)

Routine imaging is not recommended for uncomplicated acute low back pain without red flags. 2, 3, 7, 4

• The American College of Radiology recommends against obtaining imaging initially if no red flags are present 2
• This patient has no red flags: no trauma history, no neurologic deficits, no cancer history, no fever, and unremarkable medical history 2, 3, 4
• Early imaging leads to increased healthcare utilization without improving outcomes 2, 3
• Imaging should only be considered if pain persists beyond 4-6 weeks despite conservative management 2, 3, 7, 5

Adjunctive Measures to Recommend

After initiating OMT, consider these evidence-based adjuncts:

• Superficial heat therapy using heating pads for short-term pain relief 1, 2, 6, 5
• NSAIDs or acetaminophen if pharmacologic treatment is desired (ibuprofen 400 mg every 4-6 hours as needed) 1, 2, 9, 7
• Advice to stay active within pain limits and continue ordinary activities 2, 3, 7, 8

Follow-Up Strategy

• Most acute low back pain resolves within 4-6 weeks regardless of treatment 7, 4
• Reevaluate if symptoms persist or worsen after 4-6 weeks 2, 3, 5
• Consider imaging only if pain persists beyond 6 weeks or new red flags develop 2, 3, 7, 5

Common Pitfalls to Avoid

• Do not order routine imaging for uncomplicated acute low back pain, which leads to increased healthcare utilization without clinical benefit 2, 3
• Do not prescribe bed rest, as it causes deconditioning and delays recovery 2, 3, 6, 8
• Do not use systemic corticosteroids, as they are no more effective than placebo for low back pain 3, 6