Management of Uncomplicated Low Back Pain in Adults
For adults with uncomplicated low back pain without red-flag features, advise patients to remain active, provide reassurance about the favorable prognosis, and offer first-line treatment with NSAIDs or acetaminophen combined with nonpharmacologic options such as superficial heat, with imaging reserved only for persistent symptoms beyond 4-6 weeks. 1
Initial Assessment and Red-Flag Screening
Conduct a focused history and physical examination to exclude serious pathology requiring urgent intervention, including cauda equina syndrome (urinary retention/incontinence, saddle anesthesia, bilateral leg weakness), progressive motor deficits, suspected malignancy (history of cancer, unexplained weight loss, age >50 with new-onset pain), suspected infection (fever, IV drug use, immunosuppression), and fracture (significant trauma, osteoporosis, prolonged corticosteroid use). 2, 3, 4
Perform neurological testing including motor strength assessment (hip flexion L2, knee extension L3-L4, ankle dorsiflexion L4-L5, great-toe extension L5, ankle plantarflexion S1), sensory examination, deep-tendon reflexes (patellar L4, Achilles S1), and straight-leg raise test to identify radiculopathy or spinal stenosis. 2
Critical pitfall: Do not order imaging (X-ray, CT, or MRI) during the initial evaluation of uncomplicated low back pain, as routine imaging provides no clinical benefit, increases unnecessary healthcare utilization, and may lead to incidental findings that trigger unwarranted interventions. 3, 4
Patient Education and Activity Advice
Inform all patients of the generally favorable prognosis, with a high likelihood for substantial improvement within the first month and approximately 90% of episodes resolving within 6 weeks regardless of treatment. 1, 5
Advise patients to remain active and continue ordinary activities within the limits permitted by pain—this is more effective than bed rest and reduces disability. 1, 5
Explicitly discourage bed rest; if patients require brief periods of rest to relieve severe symptoms, encourage return to normal activities as soon as possible. 1
Provide evidence-based self-care education materials (such as "The Back Book") to supplement clinician-provided information, as these are inexpensive and nearly as effective as costlier interventions. 1
First-Line Pharmacologic Management
Prescribe NSAIDs (ibuprofen 400-800mg three times daily, naproxen 500mg twice daily, or diclofenac 50mg twice daily) as first-line medication, providing moderate short-term pain relief with stronger evidence than acetaminophen. 3, 4
Offer acetaminophen (up to 4g daily) as an appropriate alternative if NSAIDs are contraindicated, though it has slightly less robust efficacy evidence. 3, 4
Consider skeletal muscle relaxants for short-term use if NSAIDs or acetaminophen provide insufficient relief, though they carry moderate sedation risk. 1, 4
Avoid systemic corticosteroids entirely, as good-quality evidence demonstrates no benefit over placebo. 3, 4
Reserve opioids as a last resort only for severe, disabling pain uncontrolled by other measures, using time-limited courses with careful monitoring due to abuse potential and lack of superior efficacy. 3, 4
Monitor all NSAID use for gastrointestinal, cardiovascular, and renal adverse effects, using the lowest effective dose for the shortest duration; consider co-administration with a proton-pump inhibitor in higher-risk patients. 3, 4
First-Line Nonpharmacologic Management
Recommend application of superficial heat using heating pads or heated blankets for short-term relief of acute low back pain. 1, 3
Consider spinal manipulation (by a trained practitioner) for acute low back pain, as it provides small-to-moderate short-term improvements in pain and function. 1, 4
Other nonpharmacologic options with evidence for acute/subacute pain include massage and acupuncture, though the quality of evidence is lower than for heat and manipulation. 3
Do not recommend supervised exercise programs during the acute phase (<4 weeks), as they have not demonstrated effectiveness for acute low back pain. 4
Reassessment and Imaging Timing
Reassess patients at 1 month if symptoms persist without improvement; consider earlier reevaluation (within 2-4 weeks) for patients over 65 years, those with signs of radiculopathy or spinal stenosis, or those with worsening symptoms. 2, 3, 4
Order imaging (plain radiography initially, or MRI if radiculopathy is suspected) only after 4-6 weeks of failed conservative therapy in patients who are potential candidates for surgery or interventional procedures. 1, 2
Early imaging (<6 weeks) is associated with higher rates of unnecessary injections, surgical procedures, and disability claims without improving outcomes, as most disc herniations spontaneously reabsorb by approximately 8 weeks. 2, 4
Management of Persistent or Chronic Symptoms
For symptoms persisting beyond 4-6 weeks, intensify nonpharmacologic therapies including exercise therapy, multidisciplinary rehabilitation, acupuncture, cognitive-behavioral therapy, mindfulness-based stress reduction, tai chi, yoga, or continued spinal manipulation. 3
Screen for psychosocial risk factors (depression, catastrophizing, fear-avoidance beliefs, job dissatisfaction) that predict progression to chronic disabling pain, using tools such as the STarT Back questionnaire to risk-stratify patients. 2, 3
Consider referral to physical therapy for medium-risk patients and comprehensive biopsychosocial assessment for high-risk patients, with review no later than 12 weeks from symptom onset. 3
For inadequate response to nonpharmacologic therapy in chronic low back pain, escalate pharmacologically with tramadol or duloxetine as second-line options before considering opioids as a last resort. 3
Common Pitfalls to Avoid
Never order imaging before 6 weeks unless red flags are present, as disc abnormalities are common in asymptomatic individuals (present in up to 43% of asymptomatic 80-year-olds) and often do not correlate with symptoms. 2, 4
Do not prescribe prolonged bed rest, as maintaining activity is more effective and reduces disability. 1, 5
Avoid overreliance on opioid medications for initial or long-term pain management due to abuse potential and lack of superior efficacy compared to NSAIDs. 3, 4
Do not delay specialist referral beyond 3 months for persistent symptoms despite comprehensive conservative therapy, as this can lead to prolonged disability. 2, 3