What is the recommended clinical practice guideline for the evaluation and management of non‑specific low back pain in adults?

Clinical Practice Guideline for Low Back Pain

For adults with acute or subacute non-specific low back pain, prioritize nonpharmacologic treatments—specifically superficial heat, massage, acupuncture, or spinal manipulation—and only add NSAIDs or skeletal muscle relaxants if the patient specifically requests medication. 1

Initial Assessment and Red Flag Screening

Conduct a focused history and physical examination specifically to identify red flags that require urgent intervention:

• Severe or progressive neurologic deficits (weakness, numbness, bowel/bladder dysfunction) 2, 3
• Cauda equina syndrome 3
• History of cancer with unexplained weight loss 3
• Fever suggesting infection 3
• Significant trauma or history of osteoporosis suggesting fracture 3
• Midline tenderness with fever or recent infection suggesting vertebral infection 3

If red flags are present, obtain immediate MRI (preferred over CT due to superior soft tissue visualization and no radiation) and arrange urgent specialist consultation. 3

If no red flags are present, do NOT order imaging—routine X-rays, MRI, or CT for uncomplicated low back pain do not improve outcomes and expose patients to unnecessary radiation. 2, 3

Patient Education and Activity Modification

Reassure patients that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment. 2

Explicitly instruct patients to remain active and continue ordinary activities within pain limits—bed rest is contraindicated and worsens outcomes. 2, 1

Recommend a medium-firm mattress rather than a firm mattress, as firm mattresses are less likely to lead to improvement. 2

Treatment Algorithm by Duration

Acute Low Back Pain (<4 weeks)

First-line nonpharmacologic treatments (strong recommendation):

• Apply superficial heat using heating pads or heated blankets (moderate-quality evidence) 1, 2
• Massage therapy (low-quality evidence) 1
• Acupuncture (low-quality evidence) 1
• Spinal manipulation by appropriately trained providers (low-quality evidence) 1

Pharmacologic options only if patient specifically requests medication:

• NSAIDs as first choice (moderate-quality evidence)—provide approximately 10 points greater pain relief on a 100-point visual analogue scale compared to acetaminophen 1, 2
• Acetaminophen up to 3000-4000mg daily as alternative with more favorable safety profile but slightly less efficacy (moderate-quality evidence) 1, 2
• Skeletal muscle relaxants (moderate-quality evidence) 1

Avoid these interventions for acute pain:

• Exercise therapy and supervised home exercise regimens are NOT effective for acute low back pain 1
• Systemic corticosteroids are ineffective and should not be used 1, 2
• Opioids should be avoided for initial management 2

Subacute Low Back Pain (4-12 weeks)

Intensive interdisciplinary rehabilitation is moderately effective and should be considered. 1

Functional restoration with a cognitive-behavioral component reduces work absenteeism in occupational settings. 1

Many trials enrolled mixed populations with chronic and subacute symptoms, so treatments effective for chronic pain may reasonably be applied to subacute cases. 1

Chronic Low Back Pain (>12 weeks)

First-line nonpharmacologic treatments (strong recommendation):

• Exercise therapy (moderate-quality evidence) 1
• Multidisciplinary rehabilitation (moderate-quality evidence) 1
• Acupuncture (moderate-quality evidence) 1
• Mindfulness-based stress reduction (moderate-quality evidence) 1
• Tai chi (low-quality evidence) 1
• Yoga (low-quality evidence) 1
• Motor control exercise (low-quality evidence) 1
• Progressive relaxation (low-quality evidence) 1
• Cognitive behavioral therapy (low-quality evidence) 1
• Spinal manipulation (low-quality evidence) 1
• Massage therapy (low-quality evidence) 1

Pharmacologic escalation for inadequate response to nonpharmacologic therapy:

1. First-line: NSAIDs (weak recommendation, moderate-quality evidence) 1
2. Second-line: Tramadol or duloxetine (weak recommendation, moderate-quality evidence) 1
3. Last resort: Opioids only after failure of all above treatments, only if potential benefits outweigh risks, and only after discussion of known risks and realistic benefits with patient (weak recommendation, moderate-quality evidence) 1

Additional medication considerations for chronic pain:

• Tricyclic antidepressants are an option for pain relief in patients with chronic low back pain without contraindications 1
• Gabapentin provides small, short-term benefits in patients with radiculopathy 1
• Selective serotonin reuptake inhibitors and trazodone have NOT been shown effective for low back pain 1
• Benzodiazepines are similarly effective to skeletal muscle relaxants for short-term pain relief but carry risks for abuse, addiction, and tolerance—use only time-limited courses if prescribed 1

Psychosocial Assessment

Screen for and address psychosocial risk factors that predict chronic disabling back pain:

• Depression and anxiety 2, 1
• Job dissatisfaction 2
• Fear-avoidance beliefs 2
• Catastrophizing 2

Depression commonly coexists with chronic back pain and should be treated appropriately—note that SSRIs are not effective for back pain itself but may be needed for comorbid depression. 1

Follow-up and Reassessment

Reevaluate patients at 1 month if symptoms persist without improvement. 3

Consider earlier reassessment for:

• Patients over 65 years 3
• Signs of radiculopathy or spinal stenosis 3
• Worsening symptoms 3

If symptoms persist beyond 4-6 weeks despite conservative management, consider plain radiography as initial imaging option. 3

Consider referral or consultation when:

• No response to standard noninvasive therapies after 3 months minimum 3
• Progressive neurologic deficits 3
• Persistent functional disabilities and pain despite comprehensive conservative therapy 3

Critical Safety Considerations

When prescribing NSAIDs:

• Assess cardiovascular and gastrointestinal risk factors before prescribing 2
• Use lowest effective dose for shortest duration 2
• Consider co-administration with proton-pump inhibitor in higher-risk patients 2
• Monitor for gastrointestinal and renal toxicity, especially in patients with pre-existing kidney disease 2

Skeletal muscle relaxants carry risks:

• Tizanidine carries a black box warning for potentially fatal hepatotoxicity 1
• Chlorzoxazone is associated with generally reversible hepatotoxicity 1

Extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events, as evidence on long-term use is limited. 1

Common Pitfalls to Avoid

• Do not order routine imaging for uncomplicated acute low back pain—findings are often nonspecific and do not improve outcomes 2, 3
• Do not prescribe bed rest—it increases disability and worsens outcomes 2
• Do not use systemic corticosteroids—they are no more effective than placebo 1, 2
• Do not prescribe opioids as first-line therapy—reserve only for patients who have failed all other treatments 1
• Do not use firm mattresses—medium-firm mattresses are more likely to lead to improvement 2