Acute low back pain

Low back pain is a leading contributor to disability in New Zealand; it is only rarely a life-threatening condition, but it represents a significant health burden both to patients and the healthcare system. Primary care clinicians have a key role in implementing early interventions to reduce the likelihood of patients progressing to chronic low back pain and associated disability.

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Published: 20 May 2022


Key practice points:

  • Low back pain affects up to 80% of people at some stage during their lifetime; approximately half of these people seek medical advice or treatment
  • Most people with acute low back pain have restoration of function within a few weeks to months, however, many people have ongoing pain one year after an acute episode; the aim of management is to effectively treat acute low back pain to reduce the risk of chronic disability
  • Serious causes of low back pain are rare and can usually be excluded with a detailed history and targeted physical examination
  • Laboratory investigations or imaging are generally not required in patients with acute low back pain in the absence of red flags; an exact diagnosis is often not possible, nor needed, for management
  • Patient beliefs and attitudes warrant as much attention as the anatomical and pathological aspects of their condition. Fear about pain is a major determinant of disability and possible chronicity; educate patients about the favourable prognosis of acute low back pain and provide them with a plan to self-manage any relapses.
  • Management should be focused on coping strategies, non-pharmacological interventions, e.g. stretching, relaxation techniques, superficial hot-cold applications, and education and advice on keeping active and returning to normal daily activities
  • There is limited evidence for pharmacological treatments for non-specific acute low back pain, but analgesia may be required short term; long-term use should be avoided.
  • Ideally schedule a follow-up appointment to monitor treatment progress, check adherence to the treatment regimen and reinforce recommendations

In this article we feature expert commentary from Musculoskeletal Medicine Specialist and General Practitioner, Dr Jeremy Steinberg.

This is a revision of a previously published article. What’s new for this update:

  • A full article revision and update of evidence
  • Key changes in the management of acute non-specific low back pain include:
    • Prioritise non-pharmacological management strategies
    • Pharmacological treatments should be reserved for severe pain and if required, should be taken alongside non-pharmacological interventions at the lowest potency, the lowest effective dose and for the shortest possible duration
    • NSAIDs show greater efficacy compared to paracetamol when taken alone for the management of acute non-specific low back pain
  • A new section has been added on managing persistent low back pain

Low back pain involves discomfort, muscle tension or stiffness, arising from components of the lumbosacral spine. Pain may radiate to the groin, buttocks or legs as somatic referred pain or may be radicular pain, i.e. sciatica, indicating potential nerve root involvement.1

Low back pain is defined by the length of time that it has been present:2

Prompt and appropriate management of people with acute low back pain is essential to reduce the risk of progression to chronic pain and associated disability, however, only half of all people with low back pain seek advice or treatment.2

The exact cause and origin of acute low back pain is largely unknown

Unlike with chronic low back pain, for most people with acute low back pain it is usually not possible to identify the specific cause, i.e. to make a patho-anatomic diagnosis.1 Low back pain can result from numerous known and unknown structural and functional abnormalities or disease processes; severity of pain and associated disability is also influenced by multiple factors, including pain processing mechanisms, biopsychosocial factors and patient co-morbidities.1

There are three main classifications of acute low back pain:3, 4

  1. Non-specific acute low back pain (90 – 95% of cases in primary care)
    • Lumbar musculoskeletal origin – a diagnosis of exclusion
  2. Radicular syndrome (5 – 10% of cases in primary care)
    • Radicular pain, radiculopathy
  3. Serious pathology* (< 1% of cases in primary care)
    • Vertebral or sacral fracture, primary tumours and metastases, spinal infection, axial spondyloarthritis, cauda equina syndrome

*N.B. Serious non-spinal pathology can also present as back pain, e.g. abdominal aortic aneurysm (Table 1), pyelonephritis, pancreatitis or prostatitis.

Once established that the patient has acute low back pain, begin by taking a focused history and then perform a physical examination guided by relevant clues.4 Consider any red flags in the history or examination that could indicate a serious cause that requires further investigation or referral (Table 1).3

Key questions for assessing a patient with acute low back pain

As part of the patient history, ask about:

Base the examination on patient history

The clinical examination of a patient with acute low back pain assists with determining the differential diagnosis. Clues from the patient history can be reinforced by positive examination findings to detect serious underlying conditions (Table 1), nerve root involvement (Table 2) or referred pain, e.g. pancreatitis, prostatitis, pyelonephritis, pregnancy-related pain.3 Examination can also help to quantify the severity of the patients symptoms.

Guided by the patient history and the nature and site of the pain, the physical examination may include:8, 9

  • Observation of the posture, gait and general demeanour of the patient when they enter the consultation room
  • Palpation of the spine to try to localise the pain and identify a vertebral level; while this is not often diagnostically useful for acute pain it helps to reassure the patient that their pain is being taken seriously, and any lack of tenderness raises suspicion of a non-musculoskeletal disorder
  • Assessment for swelling, deformity, muscle tone and heat. If infection is suspected, check body temperature.
  • Assessment of spinal range of motion, as tolerated
  • Palpation of the abdomen for abdominal mass or abdominal aortic aneurysm, if suspected
  • Neurological examination; although this is usually only necessary if the patient has weakness, numbness or radicular pain. For patients with pure low back pain, a quick neurological assessment (optional) is to observe them walking on their heels and toes and to test sensation with light touch over the feet.

For a reminder on how to examine the lumbar spine, see: https://stanfordmedicine25.stanford.edu/the25/BackExam.html


Table 1. Red flags that may indicate a serious underlying cause of low back pain.3, 4, 10–14

Potential diagnosis

(prevalence in primary care)

Red flags Investigations*

Vertebral or sacral fracture

(0.7 – 4.5%)

  • Older age (> 65 years male, > 75 years female)
  • Midline tenderness in a patient with a history of significant trauma
  • History of osteoporosis
  • History of cancer
  • Sporting activity involving spinal extension, rotation or both (Pars interarticularis stress fracture)
  • Prolonged systemic corticosteroid use
  • Significant trauma

X-ray or referral for consideration of CT scan. MRI is often preferred for suspected stress fractures (ideally to detect stress reaction before a stress fracture occurs).

Axial spondyloarthritis

(0.1 – 1.4%)

Chronic low back pain (> 12 weeks) with onset before aged 45 years and one or more of the following:

  • Inflammatory back pain with at least four of: insidious onset, onset aged ≤ 40 years, improvement with activity, no improvement with rest, pain at night (with improvement when getting up)
  • Peripheral manifestations, e.g. arthritis, enthesitis, dactylitis
  • Extra-articular manifestations, e.g. psoriasis, inflammatory bowel disease, uveitis
  • Family history of spondyloarthritis
  • Response to NSAIDs

Laboratory tests, e.g. CRP, HLA-B27. Referral for consideration of MRI to assess for sacroiliitis.

Spinal malignancy

(0.2%)

  • Personal history of malignancy
  • Age > 50 years
  • Unexplained weight loss
  • Pain not relieved by rest
  • Strong clinical suspicion

Laboratory tests, e.g. FBC, CRP and PSA if male. Imaging – MRI is often preferred because plain X-rays are not as specific or sensitive for detecting spinal malignancy.

Cauda equina syndrome

(0.04%)

  • Bilateral leg symptoms, including bilateral lumbar radicular pain, lower limb weakness, sensory changes or progressive neurological deficits
  • Urinary dysfunction, including impaired bladder or urethral sensation, hesitancy, urgency or poor stream
  • Altered perineal sensation (subjective or objective) and reduced anal tone on per rectum examination

Cauda equina syndrome is an emergency, refer immediately for acute orthopaedic or neurosurgical assessment

Spinal infection

(0.01%)

  • Fever (> 37.8°C), night sweats or chills
  • Pain at rest or at night
  • Immunosuppression
  • Diabetes
  • Alcohol use disorder
  • Intravenous drug use
  • Recent injury, dental or spinal procedure

Laboratory tests, e.g. FBC, CRP (or ESR**), and imaging – MRI preferred

Aneurysm, e.g. abdominal aortic aneurysm

(1 – 2%)

  • Palpable abdominal pulsatile mass
  • High cardiovascular disease risk
  • Anticoagulant use
  • Absence of musculoskeletal signs

Laboratory tests, e.g. FBC, renal function, lipids, HbA1c, to assess cardiovascular risk

Referral for ultrasound

Urgent vascular surgery assessment if pulsatile mass is tender or patient with known AAA has new onset pain

* If there is not convincing evidence of a serious aetiology from the patient history and examination, but still suspicion, consider a “watchful waiting” approach and review the patient within one to two weeks3

See: https://bpac.org.nz/BPJ/2016/July/spondyloarthritis.aspx and https://bpac.org.nz/update-series/systems.aspx for further information

Urinary retention or overflow incontinence, faecal incontinence and perineal anaesthesia are considered “white flags” – meaning defeat or surrender – and indicate that the diagnosis of cauda equina syndrome has been made too late.7 Impaired anal tone is occasionally considered a white flag; normal tone should not be a factor in deciding whether to refer in the correct clinical context.7 By the time white flags become apparent, the patient may not fully recover despite treatment.7

** ESR can be considered if CRP is not elevated but clinical suspicion for spinal infection remains. CRP and ESR both have high sensitivity for spinal infections, however, ESR testing may not be funded for this indication at all laboratories.15

Referred Pain Syndromes

During the clinical history and examination (including neurological assessment), consider symptoms and signs of nerve root involvement as a potential indicator of radicular pain or radiculopathy (Table 2).3, 4 Radiculopathy occurs as a result of neural compression from any cause, whereas radicular pain involves the addition of inflammation e.g. from an inflamed herniated nucleus pulposus.1 It is important not to confuse radicular pain with somatic referred pain, which is caused by pain radiating from a somatic structure such as a facet joint, sacroiliac joint, muscle or intervertebral disc without nerve root involvement. However, they can co-exist, e.g. a herniated disc can cause somatic referred pain from irritation of the dura of the nerve root plus radicular pain from irritation of the nerve root itself.


Table 2. Symptoms and signs of radiculopathy, radicular pain and somatic referred pain.1, 3, 4

Symptoms and signs

Radiculopathy –

occurs due to neural compression

  • Objective loss of sensory or motor function (due to conduction block in axons of a spinal nerve or its roots)
  • Numbness or paraesthesia in dermatomal distribution
  • Weakness or loss of function (L1 – S1), e.g. footdrop
  • Reduced leg reflexes (knee jerk for L3 – 4, medial hamstring for L5, ankle jerk for S1)
  • May or may not be associated with radicular pain

Radicular pain –

occurs due to nociceptive discharge of a nerve root or dorsal root ganglion typically in the presence of inflammation, with pain being felt in the peripherally innervated structures of the affected nerve

  • Leg pain greater than back pain (and not temporally linked to back pain)
  • Unilateral leg pain radiating caudally in a narrow band in a quasi-dermatomal distribution, with possible skip regions
  • Sharp, lancinating, deep as well as superficial pain
  • Leg pain exacerbated by coughing, sneezing or straining
  • Positive crossed or straight leg raise test or positive slump test (L4, L5, S1, S2)
  • Positive femoral stretch test (L2, L3, L4)
  • Occasionally there are symptoms and signs of radiculopathy

Somatic referred pain –

occurs due to nociceptive fibre convergence from the lower back onto second order neurons in the dorsal horn that also receive input from the lower limb

  • Dull, deep ache, like an expanding pressure
  • Referred pain concurrent with back pain, i.e. if the back pain resolves, or flares, then so does the referred pain
  • Pain can be referred as far down as the foot when severe with possible skip regions
  • Pain initially felt widely with difficult to perceive boundaries; pain remains in one location once established
  • Absence of neurological symptoms or signs
  • Can co-exist with radicular pain

For information on the management of patients with radicular syndrome, see: “Management of patients with radicular syndrome

Diagnostic laboratory investigations, e.g. FBC, CRP, or imaging, e.g. lumbar X-ray, MRI, are not routinely recommended for patients with acute low back pain unless there is suspicion of a serious underlying cause (Table 1), or if the results are likely to change management.4, 18

The benefit of investigation needs to be weighed up against the potential for harm, e.g. exposure to radiation, detection of unrelated abnormalities, health anxiety and unnecessary follow-up.4 Changes unrelated to back pain such as disc bulges on MRI or degenerative changes on plain X-ray films are common incidental findings from imaging, with increasing prevalence with age.1, 4

In the correct clinical context, imaging and laboratory testing may be appropriate if there is no improvement in pain after four to six weeks (see: “Persistent low back pain”).9, 18

Dr Steinberg says:There are competing interests with ordering investigations. On the one hand serious pathologies are very commonly missed at the initial assessment, e.g. approximately 50% of patients with spinal infection are initially misdiagnosed.a New Zealand research has found evidence that access criteria for MRI may be too strict in the public system with very high pick-up rates of serious conditions (1 in every 6.5 patients scanned),b suggesting that not enough MRIs are being done. On the other hand, serious conditions are rare overall and ordering unnecessary investigations has its own problems.

  • Patel AR, Alton TB, Bransford RJ, et al. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. The Spine Journal 2014;14:326–30. https://dx.doi.org/10.10.1016/j.spinee.2013.10.046.
  • Street KJ, White SG, Vandal AC. Clinical prevalence and population incidence of serious pathologies among patients undergoing magnetic resonance imaging for low back pain. The Spine Journal 2020;20:101–11. https://dx.doi.org/10.10.1016/j.spinee.2019.09.002

Most people with acute non-specific low back pain have a favourable prognosis and can expect a significant improvement in their symptoms within six weeks.2 Subsequent relapse, however, is common with many people experiencing a recurrent episode within one year of the original episode.2 Over 40% of people with acute low back pain that has not improved within six weeks may go on to develop chronic low back pain and associated disability (see: “Persistent low back pain”).2

Pain is an individual experience influenced by multiple factors, including the biomedical process, patient perception, pain history, ability to cope, mental wellbeing and family and cultural background.19 Studies suggest that influencing the beliefs, misconceptions and attitudes about back pain is an essential component of successful management and in achieving optimal health outcomes for the patient.20

Best Practice Tip: When discussing non-specific low back pain, avoid language that promotes belief about structural damage, e.g. “degeneration” or “wear and tear”, and language that promotes fear and catastrophic thinking, e.g. “avoid bending or lifting”, “let pain be your guide”, “stop if you feel pain” or “you have to be careful”.2, 21

As part of general management advice:2, 4

  • Involve the patient in their management plan and discuss what has or has not worked for them in the past, including allied health services. Ensure patients have a realistic expectation of what a pain management strategy will achieve. A treatment regimen that resolves all pain is not usually possible.
  • Give practical reassurance, i.e. using facts and logic, not emotional reassurance, of the favourable prognosis and benign nature of acute non-specific low back pain
  • Discuss coping strategies, including distraction techniques, to manage an acute flare. A free online Australian pain coping course is available from: www.paintrainer.org/login-to-paintrainer/
  • Encourage all patients with low back pain to minimise bed rest, maintain activity and exercise and return to normal work and daily activities at the earliest possible opportunity. Explain that experiencing pain does not always mean harm and that some level of pain is to be expected with increased activity.

For further information on the principles of acute pain management, see: https://bpac.org.nz/2018/acute-pain.aspx

Risk stratification can be used to direct management

A risk stratification approach to the management of people with low back pain is increasingly being adopted internationally.2 This enables the early identification of patients who are at risk of developing chronic low back pain and associated disability (see: “Identify and manage psychosocial risk factors, i.e. ‘yellow flags’”).18

Screening tools may help with tailoring the management approach

STarTBack is a validated screening tool that assesses biopsychosocial risk factors, including fear avoidance and catastrophising, as prognostic markers for chronicity and stratifies patients into low, medium or high-risk groups.18 Patients classified as low/medium risk have a more favourable prognosis and can be managed with less intensive interventions, e.g. reassurance and advice on remaining active.22 More intensive interventions should be considered for patients who are classified as high risk, e.g. cognitive behavioural therapy (or mindfulness-based therapy) and structured exercise programmes.18, 22

For further information on STarTBack, see: https://startback.hfac.keele.ac.uk/

Prioritise non-pharmacological interventions

As part of a shared-decision making process, discuss non-pharmacological management strategies with the patient, considering their preferences, potential harms and associated costs and availability of the intervention(s).22, 23 Pharmacological treatments are usually reserved for people with severe pain, although may be required initially to support patients while they return to their normal routine and daily activities, and during the introduction of non-pharmacological interventions (see: “Acute treatment with analgesia, if required – but with a plan to stop”).2

Examples of non-pharmacological interventions that may be discussed include:2, 8

  • Movement and activation, e.g. gradual increase in intensity of exercise, simple stretches to reduce muscle tightness, physiotherapy (although specific evidence of effectiveness in low back pain is limited)
  • Superficial hot or cold applications, e.g. use of a hot pack, taking regular warm baths or showers, using a spa or sauna. Some patients may prefer cold, e.g. ice pack.
  • Relaxation techniques, e.g. yoga, meditation/slow breathing, mindfulness
  • Distraction techniques, e.g. reading a book, listening to music, socialising, returning to work

Some patients may find other treatment modalities useful, e.g. osteopathy, chiropractic treatment, acupuncture or therapeutic massage. However, there is limited evidence of benefit for any of these modalities in acute non-specific low back pain.5, 9, 21 As part of a shared-decision making process, discuss the balance of benefit and affordability of allied health treatment, any past experiences they may have had with allied health services and how to look for a good provider by discussing their treatment approach and making sure that it is based on a biopsychosocial model.

Acute treatment with analgesia, if required – but with a plan to stop

There is limited evidence of the effectiveness of pharmacological treatments for acute non-specific low back pain. If an analgesic is required, prescribe short courses only at the lowest effective dose to avoid long-term dependence on medicines.2 NSAIDs are generally the most useful analgesic for acute low back pain, but they may not be suitable for all patients. Pharmacological treatments should always be used alongside non-pharmacological interventions. Review the patient within one to two weeks to monitor progress and make treatment adjustments, as appropriate.2

Topical preparations. A topical NSAID, e.g. diclofenac sodium (not funded), or capsaicin cream (0.025% cream funded with Special Authority approval for patients with osteoarthritis) may be better tolerated than oral analgesics for some patients, although efficacy for low back pain is unclear.24 A randomised controlled trial (including 746 participants with acute back/neck pain) in Germany found that participants applying a combination of diclofenac 2% + capsaicin 0.075%* and capsaicin alone, twice daily, for five days, experienced greater pain relief than participants applying placebo gel.25 The analgesic effect of topical diclofenac alone was comparable to placebo.25

Some patients may find topical rubefacients such as ‘Deep Heat’ (menthol + methyl salicylate) or other anti-inflammatory balms, e.g. Anti-Flamme or Tiger Balm (cajuput oil + camphor + clove oil+ menthol + mint oil), effective, however, there is limited evidence of benefit.24, 27

For further information on rubefacients, topical NSAIDs and capsaicin available in New Zealand, see: https://nzf.org.nz/nzf_5755

*This higher strength capsaicin cream is only funded in New Zealand for patients with post-herpetic neuralgia and diabetic peripheral neuropathy (with Special Authority approval)26

Paracetamol. Paracetamol may be appropriate for some patients with acute low back pain, e.g. those who cannot tolerate NSAIDs, however, evidence has demonstrated no benefit when paracetamol is taken alone compared to NSAIDs or placebo for people with non-specific low back pain.2, 9

NSAIDs. A NSAID at the lowest effective dose is generally the recommended analgesic for patients with acute non-specific low back pain, if appropriate.* 22 There is no difference in the efficacy between NSAIDs, however, people taking selective COX-2 inhibitors, e.g. celecoxib, may experience fewer gastrointestinal effects.28

*Consider patient age, co-morbidities and potential gastrointestinal, liver and cardiorenal toxicity22

Skeletal muscle relaxants. There is limited evidence that muscle relaxants are effective for people with acute low back pain.29 A short course (up to ten days) of orphenadrine may be appropriate for some patients with acute low back pain and associated muscle spasm; however, no difference in functional outcomes has been observed in people taking orphenadrine compared with naproxen.30 Benzodiazepines should be avoided; no improvement in pain has been observed in people taking diazepam and naproxen compared to those taking naproxen and placebo.31

Weak opioids, e.g. codeine, tramadol, (taken with or without paracetamol) should only be recommended for a short duration in patients with severe low back pain or when NSAIDs are contraindicated, not tolerated or ineffective.2, 22 Prescribe weak opioids with caution; the benefits of use must outweigh the potential risks.2 The use of strong opioids should be avoided.2

For further information on opioids for patients with acute pain, see: https://bpac.org.nz/2018/opioids.aspx

Gabapentinoids, e.g. gabapentin and pregabalin, should not be prescribed for patients with chronic non-neuropathic pain, e.g. non-specific low back pain, and are no longer recommended for people with sciatica due to a lack of benefit and evidence of harm.22

Antidepressants, e.g. tricyclic antidepressants (unapproved indication), are best reserved for use in people with chronic low back pain or radicular pain (see: “Management of patients with radicular syndrome” and “Persistent low back pain”).8

A routine follow-up appointment should be scheduled two weeks after the initial consultation;2 consider booking this at the initial consultation and advise the patient to cancel if their pain has resolved. Set measurable and realistic outcomes to assess treatment response, e.g. a reduction in pain score or the ability to perform a task or participate in an activity they could not do before. Pain diaries should be avoided as they encourage patients to focus on their pain, counteracting the goal of pain distraction.33

At the follow-up appointment check the patients understanding of and adherence to the treatment regimen. If there is inadequate improvement in pain despite adherence to non-pharmacological interventions (and pharmacological, if required), consider reassessment – including, repeating a focused history and physical examination to rule out the development of any red flags that may indicate a serious underlying cause (especially if the patient had presented early in the course of their pain), address any yellow flags that may be contributing to the delayed recovery and reinforce treatment recommendations (see: “Identify and manage psychosocial risk factors, i.e. ‘yellow flags’”).4, 18

Expert tip: If it becomes apparent that the patient is at high risk of developing chronic low back pain, consider early planning for referral depending on the waiting lists of local musculoskeletal specialist providers.

Persistent low back pain

Despite gold standard care, some people with acute low back pain will develop chronic low back pain that persists or fluctuates for longer than three months.18, 22 Encourage these patients to return to primary care at regular intervals to ensure that symptoms are not progressing and that no red flags have developed that indicate a serious underlying cause. Some patients may also require regular review for ACC work- and medical certificate purposes.

Although evidence of conservative treatments for chronic low back pain is limited, first-line management generally consists of persisting with the same treatments as for acute low back pain, and may include education and reassurance, self-management strategies, e.g. use of a hot and cold pack, exercise/physiotherapy, and simple analgesics, e.g. paracetamol, NSAIDs.3, 8 Co-morbidities such as anxiety and depression should also be addressed and managed.5

Second-line care usually consists of more complex medicines*, e.g. tricyclic antidepressants, cognitive behavioural therapy and multidisciplinary rehabilitation programmes, i.e. combining physical and psychological therapies, often in a group setting.3, 8, 18

*Avoid prescribing opioids to patients with chronic low back pain22

Consider referral if symptoms suggestive of a serious underlying cause develop or if pain persists after six months of appropriate management, or earlier if the pain is debilitating and significantly affecting the patients quality of life.18 Check your local HealthPathways for specific referral advice.

Clinician’s Notepad: Acute low back pain

Assessment

  • Determine
    • Site of pain
    • Pain radiation patterns
    • Mode of onset
    • Aggravating and relieving factors
    • Severity and functional impact
    • Associated “red flag” features that may indicate fracture, infection, malignancy or cauda equina syndrome (see box)
    • Any psychosocial factors that may influence recovery (“yellow flags”)
  • Perform a physical examination guided by relevant clues in the patient history
    • Observe the posture, gait and general demeanour of the patient
    • Palpate the spine to try to localise the pain and identify a vertebral level
    • Assess for pain, swelling, deformity, muscle tone and heat. If infection is suspected, check body temperature.
    • Assess spinal range of motion, as tolerated
    • Palpate abdomen for abdominal mass or abdominal aortic aneurysm, if suspected
    • Perform a neurological examination if neurological symptoms are present
  • Diagnostic laboratory investigations, e.g. FBC, CRP, or imaging, e.g. lumbar X-ray, MRI, are not routinely recommended, unless there is suspicion of a serious underlying cause or if the results are likely to change management
  • Exclude other possible causes of low back pain, e.g. referred visceral pain, pregnancy, vascular causes, axial spondyloarthritis, radicular syndromes

Red flags

  • Aged > 50 years with new onset back pain, especially aged > 65 years
  • History of malignancy with other features, e.g. unexplained weight loss
  • Severe worsening or unrelenting pain, particularly at night or when supine
  • History of trauma, or risk factors for fracture, e.g. osteoporosis, older age, prolonged systemic corticosteroid use
  • Significant neurological symptoms, e.g. bilateral radicular pain or radiculopathy, impaired bladder/urethral sensation, urinary hesitancy or urgency, poor stream, loss of perineal sensation
  • Symptoms or signs of infection, e.g. fever (> 37.8°C), night sweats or chills; or risk factors for infection, e.g. intravenous drug use, immunosuppression
  • Cardiovascular risk factors for aneurysm, e.g. smoking history, hypertension, older age, male sex

Management of acute non-specific low back pain

  • Involve the patient in their management plan and discuss what has or has not worked for them in the past, including allied health services. Ensure that patients have a realistic expectation of what a pain management strategy will achieve.
  • Give practical reassurance, i.e. using facts and logic, not emotional reassurance, of the favourable prognosis and benign nature of acute non-specific low back pain
  • Discuss coping strategies, including distraction techniques, to manage an acute flare
  • Encourage patients to remain physically active, minimise bed rest and return to normal work and daily activities as soon as possible. Explain that experiencing pain does not always mean harm and that some level of pain is to be expected with increased activity.
  • Assess for risk of progression to chronic low back pain, e.g. using STarTBack
  • Prioritise non-pharmacological interventions, e.g. superficial hot-cold applications, relaxation and distraction techniques, exercise, physiotherapy
  • Pharmacological treatments have limited evidence of effectiveness and are usually reserved for people with severe pain, although may be required initially to support patients while they return to their normal routine and daily activities, and during the introduction of non-pharmacological interventions
  • If an analgesic is required, trial a NSAID (or paracetamol) and prescribe short courses only at the lowest effective dose to avoid long-term dependence on medicines. Pharmacological treatments should always be used alongside non-pharmacological interventions.

Follow-up

  • Review the patient after two weeks of treatment to assess response
    • If there is not adequate improvement, consider reassessment, including repeating a focused history and physical examination to rule out the development of any red flags and address any yellow flags that may be contributing to delayed recovery
  • If the patient has developed persistent low back pain:
    • Encourage them to return to primary care at regular intervals to ensure that symptoms are not progressing and that no red flags have developed
    • Continue with treatments used for acute pain, e.g. education, reassurance, self-management strategies and simple analgesics
    • Address and manage any co-morbidities, e.g. anxiety or depression
    • More complex medicines, cognitive behavioural therapy and multidisciplinary rehabilitation programmes are generally reserved for second-line care only if other interventions are not successful
    • Consider referral if symptoms suggestive of a serious underlying cause develop or if debilitating pain persists after six months of appropriate management

Acknowledgement

Thank you to Dr Jeremy Steinberg, Musculoskeletal Medicine Specialist and General Practitioner, Auckland, for expert review of this article

N.B. Expert reviewers do not write the articles and are not responsible for the final content. bpacnz retains editorial oversight of all content.


Stephen Hoskin 30 May 2022 07:20
Jeremy Steinberg 31 May 2022 23:17

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