Management of acute simple low back pain

Assessment:

• carry out diagnostic triage
• if simple back pain then X-rays not routinely indicated
• consider psychosocial factors

Drug therapy:

• regular analgesia not p.r.n
• initial treatment is with analgesia e.g. paracetamol and NSAIDs e.g. ibuprofen or diclofenac. If this combination does not achieve satisfactory analgesia then consider substitution of paracetamol with paracetamol-weak opioid compound e.g. cocodamol. Consider the short term use of a muscle relaxant e.g. baclofen or diazepam (1).

Bed rest:

• prolonged bed rest is not recommended. If bed rest is needed (patients with severe leg pain initially) it should be limited, not recommended as a treatment for simple back pain.
• occasionally patients may be confined to bed for a few days as a consequence of their pain but this should not be considered a treatment.

Advice on staying active:

• patients should be advised to stay as active as possible and to continue normal daily activities since their pain is likely to resolve afterwards (2)
• patients should be advised to increase their physical activities over a few days or weeks
• patients should be advised to stay at work or return to work as soon as possible
• activities which increase mechanical stress to the spine should be limited or avoided if possible (e.g. – prolonged unsupported sitting, heavy lifting, bending or twisting the back) (2)

Manipulation:

• manipulative treatment should be considered within the first 6 weeks for patients who need additional help with pain relief or who are failing to return to normal activities

Exercises:

• patients who have not returned to ordinary activities, structured exercise programmes should be introduced according to individual needs
• may include aerobic activity, movement instructions, muscle strengthening, postural control, stretching (3)

Other useful management options are:

• icepacks or heat can be applied to the sore area to relieve pain
• relaxation to reduce tension
• acupuncture (3)

Notes:

• reviews have examined the evidence base for treatments of acute low back pain (4,5)
  • non-pharmalogical treatment options
    • therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat
  • pharmalogical treatment options
    • medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen (paracetamol), skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications

Reference:

• (1) Welsh Medicines Resources Centre (WeMeReC). Management of acute low back pain. WeMeReC Bulletin 2008.
• (2) Institute for Clinical System Improvement (ICSI) 2008. Health care guideline: Adult low back pain
• (3) National Institute for Health and Clinical Excellence (NICE) 2009. Low back pain – Early management of non-specific low back pain
• (4) Chou R et al. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.Ann Intern Med. 2007 Oct 2;147(7):492-504.
• (5) Chou R et al. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.Ann Intern Med. 2007 Oct 2;147(7):505-14.