First-Line Management of Uncomplicated Low Back Pain
For uncomplicated low back pain, prioritize non-pharmacologic therapies—specifically superficial heat, massage, acupuncture, or spinal manipulation—before offering any medication, and only add NSAIDs or skeletal muscle relaxants if the patient explicitly requests pharmacologic treatment. 1
Immediate Reassurance and Activity Guidance
Reassure patients that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment and emphasize this favorable natural history to reduce anxiety and catastrophizing. 1
Instruct patients to remain active and continue ordinary activities within pain limits—this is more effective than bed rest and reduces disability. 1, 2, 3
Explicitly advise against bed rest, as it is associated with increased disability, worse outcomes, and prolonged recovery. 1, 2, 4
Conduct a focused history and physical examination to identify red flags requiring urgent intervention: cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction), severe or progressive neurologic deficits (weakness, numbness), history of cancer, unexplained weight loss, fever suggesting infection, significant trauma, or osteoporosis with midline tenderness suggesting fracture. 5, 6
First-Line Non-Pharmacologic Therapies
Apply these modalities before considering medication:
Superficial heat (heating pads or heated blankets) is the strongest first-line non-pharmacologic option with moderate-quality evidence showing short-term pain relief effective at 4-5 days. 1, 6
Massage therapy may be offered for acute pain, with low-quality evidence supporting small to moderate benefit. 1
Acupuncture may be offered for acute pain, with low-quality evidence supporting efficacy. 1
Spinal manipulation by appropriately trained providers (chiropractors, osteopaths, or trained physical therapists) may be offered for acute pain, with low-quality evidence showing small to moderate short-term benefits. 1
Pharmacologic Options (Only If Patient Requests)
If the patient explicitly requests medication after non-pharmacologic options:
NSAIDs are the preferred first-line medication, providing approximately 10 mm greater pain relief on a 100 mm visual analogue scale compared to acetaminophen, with moderate-quality evidence. 1, 7
Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs—use the lowest effective dose for the shortest duration, and consider co-administration with a proton-pump inhibitor in higher-risk patients. 8
Acetaminophen (up to 3-4 g/day) is an alternative with a more favorable safety profile but slightly less analgesic effect than NSAIDs. 1, 7
Skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) are an option for short-term relief when muscle spasm contributes to pain, with moderate-quality evidence. 1, 7
Critical Interventions to Avoid
Do not order imaging (X-rays, MRI, CT) for nonspecific low back pain without red flags—routine imaging does not improve outcomes and may lead to unnecessary interventions. 1, 6
Do not prescribe systemic corticosteroids—they are ineffective with moderate-quality evidence showing no benefit over placebo. 1, 4
Do not prescribe opioids as first-line therapy—they should be reserved only after failure of all other recommended treatments due to abuse potential and lack of superior efficacy. 1, 7
Do not recommend exercise therapy or supervised home-exercise programs for acute pain (<4 weeks)—moderate-quality evidence shows they are ineffective in the acute phase. 1, 3
Follow-Up and Escalation
Reevaluate at 1 month if symptoms persist without improvement, or earlier in patients over 65 years, those with signs of radiculopathy or spinal stenosis, or worsening symptoms. 1, 6
If symptoms persist beyond 4-6 weeks despite conservative management, consider plain radiography as initial imaging and referral for physical therapy or more intensive rehabilitation. 6
For subacute pain (4-12 weeks), consider intensive interdisciplinary rehabilitation with moderate-quality evidence showing benefit, particularly functional restoration programs that include a cognitive-behavioral component to reduce work absenteeism. 1
Common Pitfalls
Failing to assess psychosocial risk factors (depression, anxiety, job dissatisfaction, fear-avoidance beliefs, catastrophizing) that predict progression to chronic disabling pain—these should be identified early using tools like the STarT Back questionnaire. 1, 6
Prescribing medication without first offering non-pharmacologic options—the evidence strongly supports non-pharmacologic therapies as first-line, with medication reserved only for patients who specifically request it. 1
Ordering imaging to "rule out" pathology in uncomplicated cases—this exposes patients to unnecessary radiation, increases costs, and often reveals nonspecific findings that do not change management. 1, 6