Management for acute nonspecific low back pain

Artus, 2010DePalma, 2015Hill and Fritz, 2011Kamper, 2015Maher, 2017Staal, 2008Traeger, 2015

In acute nonspecific low back pain, the aims of management are to reduce pain, restore and maintain physical function, minimise disability and absence from work, and reduce the risk of chronicity.

In most patients with acute nonspecific low back pain, minimal intervention is required and symptoms resolve with appropriate patient education and reassurance of favourable prognosis. Oral analgesia may be required, and nonpharmacological interventions (eg thermotherapy) may be considered based on patient preference. To reassure patients and aid confidence in self-management, schedule a review appointment at 4 to 6 weeks and advise the patient to cancel the appointment in the likely event that their pain improves.

Patient education should include:

• a discussion about the nature of the pain and why imaging is not required—most back pain is caused by a simple strain of the back and a serious underlying pathology is very unlikely; in most patients it is not possible to make a precise anatomical diagnosis on clinical or radiological grounds, or to identify a specific cause for the pain
• advice to stay active (see Staying active with nonspecific low back pain)
• encouragement to continue to work or to return to work as soon as possible (see Prevention of work-related disability in people with nonspecific low back pain)
• reassurance that recovery is likely to be quick even though pain may be severe
• an assessment and clarification of patient misconceptions about the nature of the pain, including addressing fear-avoidance behaviour and other unhelpful coping strategies that contribute to poor prognosis.

Printed or online information that reinforces these messages is useful to supplement advice provided by the clinician¹. Evidence-informed physiotherapists and other allied health clinicians can have a role in patient education, including reassuring and empowering the patient to self-manage their acute nonspecific low back pain. Referral to a general practitioner should be considered, particularly for patients with risk factors for poor prognosis (see Prognosis of nonspecific low back pain).

If there is persisting pain that is not improving by 4 to 6 weeks, reassess the patient for serious pathologies (see Excluding a serious pathology in people with back and neck pain). In patients with persisting nonspecific low back pain, early intervention to prevent progression to chronicity is important; use an integrated biopsychosocial approach to management that addresses risk factors for poor prognosis (see Prognosis of nonspecific low back pain). Components of management include:

• patient education and reassurance, including advice to stay active
• support for continuing or returning to work (see Prevention of work-related disability in people with nonspecific low back pain)
• identification and management of psychosocial factors; consider cognitive behavioural therapy and treat specific diagnoses (eg depression or anxiety)
• support for the patient’s ability to self-manage and adapt to the pain (the idea of ‘positive health’)Buchbinder, 2018
• exercise
• if required, oral analgesia
• if appropriate, thermotherapy for pain relief.