Recommendations Evidence

Diagnostic Triage

Carry out diagnostic triage

Diagnostic triage forms the basis for decisions about referral, investigation and management
Diagnostic triage of acute low back problems should be based on the clinical history and examination:

simple backache (non-specific low back pain)
nerve root pain
possible serious spinal pathology (tumour, infection, inflammatory disorders, cauda equina syndrome, etc.)

 

Recommendations Evidence

Use of x-rays

There is no indication for routine x-rays in acute LBP of less than 6 weeks in the absence of clinical red flags.

Royal College of Radiologists recommendations
Unnecessary or repeated x-rays should be avoided.
Lumbar spine x-rays involve 150 times the radiation dose of a chest x-ray.

 

Recommendations Evidence

Psychosocial factors

Assessment should include psychological, occupational and socioeconomic factors in the patient's life since such non-physical factors can complicate both assessment and treatment.

Psychological, social and economic factors play an important role in chronic back pain and disability.
Psychosocial factors are important at a much earlier stage than previously believed.
Management and the advice given to patients should consider and allow for psychosocial factors which can affect outcomes and the chance of developing chronicity.
Psychosocial factors influence a patient's response to treatment and rehabilitation
A number of clinical features are risk factors for developing chronic pain and disability.
Psychosocial features are more important risk factors for chronicity than biomedical symptoms and signs.

 

Recommendations Evidence

Drug Therapy

Advise paracetamol at regular intervals for simple back ache.

Paracetamol and paracetamol-weak opioid compounds prescribed at regular intervals effectively reduce low back pain. Comparisons of effectiveness to NSAIDs are inconsistent.
Substitute NSAIDs (eg ibuprofen or diclofenac) as second line treatment if paracetamol does not provide adequate pain control.
NSAIDs prescribed at regular intervals effectively reduce simple back ache.
Different NSAIDs are equally effective for the reduction of simple back ache.
NSAIDs are less effective for the reduction of nerve root pain.
NSAIDs can have serious adverse effects particularly at high doses and in the elderly. Ibuprofen followed by diclofenac have the lowest risk of gastrointestinal complications.
Consider replacement with paracetamol-weak opioid compound (eg co-codamol) if neither paracetamol nor NSAIDs provide adequate pain control.
Clinicians find that paracetamol-weak opioid compounds may be effective alternatives when paracetamol or NSAIDs alone do not give adequate pain control. Adverse effects
Consider adding a short course (less than 1 week) of a muscle relaxant (eg diazepam) if the above treatments do not provide adequate pain control.
Muscle relaxants effectively reduce acute back pain.
Comparisons of effectiveness between muscle relaxants and NSAIDs are inconsistent. There are no comparisons to paracetamol.
Muscle relaxants have significant adverse effects including drowsiness and potential physical dependence even after relatively short courses (i.e. one week).
Avoid naracotics such as morphine, pethidine and pentazocine if possible, and do not use for more than 2 weeks.
Strong opioids appear to be no more effective in relieving low back pain symptons than safer analgesics such as paracetamol, aspirin or other NSAIDs. (C)
Strong opioids have significant adverse effects such as decreased reaction time, clouded judgement, drowsiness and potential physical dependence. (C)

 

Recommendations Evidence

Bed rest

Do not recommend or use bed rest as a treatment for simple back pain.
The aim is to use symptomatic measures to control pain to let patients return to normal activity as rapidly as possible and to minimise bed rest. Some patients may initially be confined to bed as a consequence of their pain but this should not be considered as a treatment.

For acute or recurrent LBP with or without referred leg pain, bed rest for 2-7 days is worse than placebo or ordinary activity. It is not as effective as the alternative treatments to which it has been compared for relief of pain, rate of recovery, return to daily activities and days lost from work.

 

Recommendations Evidence

Advice on Staying Active

Advise patients to stay as active as possible and to continue normal daily activities.

Advice to continue ordinary activity can give equivalent or faster symptomatic recovery from the acute attack, and lead to less chronic disability and less time off work than 'traditional' medical treatment with analgesics as required, advice to rest and 'let pain be your guide' for return to normal acitvity.
Advise patients to increase their physical activities progressively over a few days or weeks.
Graded reactivation over a short period of days or a few weeks, combined with behavioural management of pain, makes little difference to the rate of initial recovery of pain and disability, but leads to less chronic disability and work loss.
If a patient is working, then advice to stay at work or return to work as soon as possible is probably beneficial.
Advice to return to normal work within a planned short time may lead to shorter periods of work loss and less time off work.



Recommendations Evidence

Manipulation

Consider manipulative treatment within the first 6 weeks for patients who need additional help with pain relief or who are failing to return to normal activities.

Within the first six weeks of onset of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared. However, there is no firm evidence that it is possible to select which patients will respond or what kind of manipulation is most effective.
The evidence is inconclusive as to whether manipulation for low back pain of more than six weeks duration provides clinically significant improvement in outcomes compared with other treatments. There is conflicting evidence from RCTs and systematic reviews on the effectiveness of manipulation in chronic low back pain
The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner. Manipulation should not be used in patients with severe or progressive neurological deficit in view of the rare but serious risk of neurological complication.

 

Recommendations Evidence

Back Exercises

Patients who have not returned to ordinary activities and work by 6 weeks should be referred for reactivation / rehabilitation.

On the evidence available at present, it is doubtful that specific back exercises produce clinically significant improvement in acute low back pain, or that it is possible to select which patients will respond to which exercises.
McKenzie exercises may produce some short-term symptomatic improvement in acute low back pain.
There is some evidence that exercise programmes and physical reconditioning can improve pain and functional levels in patients with chronic low back pain.
There are strong theoretical arguments for commencing exercise programmes and physical reconditioning by 6 weeks rather than later.

Source; RCGP guidelines, adapted.