Treatment of acute low back pain
- Christopher L Knight, MD
Christopher L Knight, MD
- Assistant Professor
- University of Washington
- Richard A Deyo, MD, MPH
Richard A Deyo, MD, MPH
- Kaiser Professor of Evidence-Based Family Medicine
- Oregon Health & Science University
- Thomas O Staiger, MD
Thomas O Staiger, MD
- Associate Professor
- University of Washington School of Medicine
- Joyce E Wipf, MD
Joyce E Wipf, MD
- Professor of Medicine
- University of Washington
It is estimated that up to 84 percent of adults have low back pain at some time in their lives [1,2]. The vast majority of patients seen in primary care (>85 percent) will have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified [3-5]. For most of these individuals, episodes of back pain are self-limited. Patients who continue to have back pain beyond the acute period (four weeks) have subacute back pain (lasting between 4 and 12 weeks) and may go on to develop chronic back pain (persists for ≥12 weeks) .
This discussion focuses on the initial treatment of nonspecific acute back pain. The treatment of acute low back pain from specific conditions is discussed in the appropriate topics. As examples:
●Treatment for vertebral compression fracture (see "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment")
●Treatment for lumbosacral radiculopathy (see "Acute lumbosacral radiculopathy: Treatment and prognosis")
●Treatment for lumbar spinal stenosis (see "Lumbar spinal stenosis: Treatment and prognosis")
- Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976) 1987; 12:264.
- Cassidy JD, Carroll LJ, Côté P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine (Phila Pa 1976) 1998; 23:1860.
- Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478.
- Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011; 154:181.
- Chou R. In the clinic. Low back pain. Ann Intern Med 2014; 160:ITC6.
- Carey TS, Evans AT, Hadler NM, et al. Acute severe low back pain. A population-based study of prevalence and care-seeking. Spine (Phila Pa 1976) 1996; 21:339.
- Coste J, Delecoeuillerie G, Cohen de Lara A, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994; 308:577.
- Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients' own criteria. Spine (Phila Pa 1976) 1996; 21:2900.
- Mehling WE, Gopisetty V, Bartmess E, et al. The prognosis of acute low back pain in primary care in the United States: a 2-year prospective cohort study. Spine (Phila Pa 1976) 2012; 37:678.
- Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327:323.
- Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006; 332:1430.
- Hazard RG, Haugh LD, Reid S, et al. Early prediction of chronic disability after occupational low back injury. Spine (Phila Pa 1976) 1996; 21:945.
- Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010; 303:1295.
- Wertli MM, Eugster R, Held U, et al. Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. Spine J 2014; 14:2639.
- Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008; 59:632.
- Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378:1560.
- Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med 2014; 12:102.
- Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010; :CD007612.
- Agency for Healthcare Research and Quality (AHRQ). Noninvasive treatments for low back pain. AHRQ Publication No. 16-EHC004-EF. February 2016. https://effectivehealthcare.ahrq.gov/ehc/products/553/2178/back-pain-treatment-report-160229.pdf (Accessed on March 11, 2016).
- Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; :CD000396.
- Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014; 384:1586.
- van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003; :CD004252.
- Beebe FA, Barkin RL, Barkin S. A clinical and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions. Am J Ther 2005; 12:151.
- Chou R, Peterson K, Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. J Pain Symptom Manage 2004; 28:140.
- Pareek A, Chandurkar N, Chandanwale AS, et al. Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone. Eur Spine J 2009; 18:1836.
- Childers MK, Borenstein D, Brown RL, et al. Low-dose cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm: a randomized trial. Curr Med Res Opin 2005; 21:1485.
- Friedman BW, Dym AA, Davitt M, et al. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA 2015; 314:1572.
- Reeves RR, Carter OS, Pinkofsky HB, et al. Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis 1999; 18:51.
- Hancock MJ, Maher CG, Latimer J, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet 2007; 370:1638.
- Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med 2016; 176:958.
- Fordyce WE, Brockway JA, Bergman JA, Spengler D. Acute back pain: a control-group comparison of behavioral vs traditional management methods. J Behav Med 1986; 9:127.
- Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend 2006; 81:103.
- Martell BA, O'Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 2007; 146:116.
- Reid MC, Engles-Horton LL, Weber MB, et al. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med 2002; 17:173.
- Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet 2004; 43:879.
- Beakley BD, Kaye AM, Kaye AD. Tramadol, Pharmacology, Side Effects, and Serotonin Syndrome: A Review. Pain Physician 2015; 18:395.
- Ruoff GE, Rosenthal N, Jordan D, et al. Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study. Clin Ther 2003; 25:1123.
- Mullican WS, Lacy JR, TRAMAP-ANAG-006 Study Group. Tramadol/acetaminophen combination tablets and codeine/acetaminophen combination capsules for the management of chronic pain: a comparative trial. Clin Ther 2001; 23:1429.
- Peloso PM, Fortin L, Beaulieu A, et al. Analgesic efficacy and safety of tramadol/ acetaminophen combination tablets (Ultracet) in treatment of chronic low back pain: a multicenter, outpatient, randomized, double blind, placebo controlled trial. J Rheumatol 2004; 31:2454.
- Friedman BW, Holden L, Esses D, et al. Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain. J Emerg Med 2006; 31:365.
- Eskin B, Shih RD, Fiesseler FW, et al. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med 2014; 47:65.
- Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis. J Pain 2014; 15:2.
- Brennan GP, Fritz JM, Hunter SJ, et al. Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976) 2006; 31:623.
- Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 2003; 28:1363.
- Faas A. Exercises: which ones are worth trying, for which patients, and when? Spine (Phila Pa 1976) 1996; 21:2874.
- Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005; :CD000335.
- Franke H, Fryer G, Ostelo RW, Kamper SJ. Muscle energy technique for non-specific low-back pain. Cochrane Database Syst Rev 2015; :CD009852.
- Schaafsma FG, Whelan K, van der Beek AJ, et al. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database Syst Rev 2013; 8:CD001822.
- Fritz JM, Magel JS, McFadden M, et al. Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial. JAMA 2015; 314:1459.
- van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low back pain. Cochrane Database Syst Rev 2000; :CD000335.
- Rubinstein SM, Terwee CB, Assendelft WJ, et al. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev 2012; :CD008880.
- Schneider M, Haas M, Glick R, et al. Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 2015; 40:209.
- Hurwitz EL, Morgenstern H, Kominski GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine (Phila Pa 1976) 2006; 31:611.
- Eisenberg DM, Post DE, Davis RB, et al. Addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 2007; 32:151.
- Liu L, Skinner M, McDonough S, et al. Acupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med 2015; 2015:328196.
- Furlan AD, Giraldo M, Baskwill A, et al. Massage for low-back pain. Cochrane Database Syst Rev 2015; :CD001929.
- French SD, Cameron M, Walker BF, et al. Superficial heat or cold for low back pain. Cochrane Database Syst Rev 2006; :CD004750.
- Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev 2013; :CD003010.
- van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev 2008; :CD001823.
- Traeger AC, Hübscher M, Henschke N, et al. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med 2015; 175:733.
- Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med 2001; 16:120.
- Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994; 272:1286.
- Cherkin DC, Deyo RA, Battié M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998; 339:1021.
- Initial monotherapy
- - Nonsteroidal antiinflammatory drugs
- - Acetaminophen
- Second-line combination therapy
- - Combination with muscle relaxants
- - NSAIDs and acetaminophen
- Refractory or severe pain
- - Opioids
- - Tramadol
- Other medications
- ADJUNCTIVE THERAPIES
- Exercise and physical therapy
- Spinal manipulation
- PATIENT EDUCATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS