We often get patients who are unsure of the best evidence related to low back pain. Here is a concise post showing best practices. Perhaps the two key points are:
1. Avoid Bed Rest (keep moving)
2. X-rays are usually unnecessary.
Patients with Low Risk of Serious Pathology (No Red Flags)
- 90% of episodes resolve within 6 weeks regardless of treatment [C]. Advise that minor flare-ups may occur in the subsequent year.
- Stay active and continue ordinary activity within the limits permitted by pain. Avoid bed rest [A]. Early return to work is associated with less disability.
- Injury prevention (e.g., use of proper body mechanics, safe back exercises).
- Recommend ice for painful areas and stretching exercises [D].
- McKenzie exercises [A] are helpful for pain radiating below the knee.
- Before considering surgery refer patient for physiatry consult [B], or manual therapy [D].
- If persistent disability at 2 weeks, consider referral for non-invasive therapy for improving flexibility and strength, not modalities such as heat, traction, ultrasound, transcutaneous electrical nerve stimulation (TENS).
- If persistent disability at 6 weeks, consider referral to a program that provides a multidisciplinary approach for back pain, especially if psychosocial risks to return to work exist.
- Surgical referral usually not required.
- Prescribe medications on a time-contingent basis, not pain-contingent basis.
- No drug categories have been proven to be more effective in pain control, consider side-effect profiles.
- Opiates are generally not indicated as first-line treatment. Although opiates relieve pain, early opiate use may be associated with longer disability, even after controlling for case severity [D].
- If prescribed, opiate use should be limited to short-term (i.e., two weeks).
- Diagnostic tests or imaging usually not required. Consider imaging if red flags are present, or if no improvement after 6 weeks.
Patients with High Risk of Serious Pathology (Red Flags and High Index of Suspicion)
- Cauda equina syndrome or severe or progressive neurologic deficit—refer for emergency studies and definitive care [C].
- Spinal fracture or compressions—plain lumbosacral (LS) spine X-ray [B]. After 10 days, if fracture still suspected or multiple sites of pain, consider either bone scan [C] or referral [D] before considering computed tomography (CT) or magnetic resonance imaging (MRI).
- Cancer or infection—complete blood count (CBC), urinalysis, erythrocyte sedimentation rate (ESR) [C]. If still suspicious, consider referral or seek further evidence (e.g., bone scan [C], other labs—negative plain film X-ray does not rule out disease).
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
Bibliographic Source Michigan Quality Improvement Consortium. Management of acute low back pain. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Sep. 1 p.