Low-back pain stands out as a frequent complaint encountered in primary care settings. In 2017, updated guidelines brought important shifts in how acute low-back pain should be approached in primary care. These changes emphasize non-drug treatments as the first line of defense and introduce a risk-based management strategy. Understanding these updated recommendations is crucial for effective patient care.
Key Changes in Low-Back Pain Management
Two significant updates mark the recent guidelines for managing acute low-back pain:
- Prioritizing Non-Drug Options: For initial management, nonpharmacologic approaches are now favored over medication for pain relief.
- Stratified Management Approach: The UK guideline recommends a stratified management strategy. This approach uses prognostic screening questionnaires to categorize patients based on their risk of poor outcomes, guiding treatment intensity from the outset, rather than relying solely on the patient’s response to initial treatment.
These guideline shifts are summarized in Table 1, providing a concise overview of recommended interventions. Appendix 2 (available in the original source) further details the evolution of low-back pain management over the last decade.
Table 1: Recent Guideline Recommendations for Acute Nonspecific Low-Back Pain Management
| Type | Intervention | Size of effect* | Quality of evidence* | 2016 UK guideline14 | 2017 US guideline15 |
|---|---|---|---|---|---|
| Nonpharmacologic | Advice to stay active v. bed rest | Small | Moderate† (2 RCTs)35 | Yes | Yes |
| Massage v. sham treatment | Moderate | Low (2 RCTs) | Yes, if part of an exercise program | Yes | |
| Spinal manipulation v. inert treatment | No effect | Low (3 RCTs) | Yes, if part of an exercise program | Yes | |
| Acupuncture v. sham treatment | Small | Low (3 RCTs) | Do not offer | Yes | |
| Heat v. sham treatment | Moderate | Moderate (4 RCTs) | No mention | Yes | |
| Exercise v. usual care | No effect | Low (6 RCTs) | Yes | No mention | |
| Psychologically informed physiotherapy v. usual care | No trials | N/A† | Yes, for those at high risk of poor outcome | No mention | |
| Pharmacologic | NSAIDs v. placebo | Small | Moderate (5 RCTs) | Yes | Yes, depending on patient preferences and drug risk profile |
| Muscle relaxants v. placebo | Small | Moderate (5 RCTs) | No mention | Yes, depending on patient preferences and drug risk profile | |
| Opioids v. placebo | No trials | N/A† | Yes, if NSAIDs are unsafe or ineffective; weak opioid only | Do not offer | |
| Paracetamol v. placebo | No effect | High† (2 RCTs)36 | Do not offer | Do not offer | |
| Systemic corticosteroids v. placebo | No effect | Low (2 RCTs) | No mention | Do not offer |
Note: GRADE = Grading of Recommendations Assessment, Development and Evaluation, N/A = No evidence from RCTs, NSAID = nonsteroidal anti-inflammatory drug, RCT = randomized controlled trial.
*Based on 2017 American College of Physicians guideline summary of evidence except where otherwise noted. Comparisons are to placebo, sham treatment, no treatment or usual care, and on short-term pain outcomes.
†Our summary of evidence used the GRADE approach.
Nonpharmacologic Treatment Modalities
Current guidelines emphasize patient education, recommending advice to remain active and reassurance regarding the typically favorable prognosis and low likelihood of serious underlying conditions. It’s also beneficial to inform patients about the potential for pain recurrence. While options like massage and spinal manipulation are considered, the US guidelines highlight that many cases of acute or subacute low back pain improve naturally over time, regardless of specific treatments. Recovery is often rapid within the first couple of weeks following an acute episode. Scheduling a follow-up appointment within one to two weeks of the initial visit allows for progress assessment and evaluation of the effectiveness of any initiated treatments.
Evidence supporting spinal manipulation for acute low-back pain was deemed limited in the US guideline review. Two randomized controlled trials (RCTs) involving 292 participants indicated a minor effect on function and uncertain pain relief compared to sham spinal manipulation. However, a more comprehensive systematic review of 15 RCTs (1711 participants) suggested moderate-quality evidence. This review indicated spinal manipulation was no more effective than placebo for pain reduction, but it was associated with a slight short-term pain decrease compared to other treatments (roughly 10 points on a 100-point scale). It’s worth noting that spinal manipulation was reported to cause short-term pain increase in 50% to 67% of patients in some studies.
Patient education plays a significant role. A systematic review of 14 RCTs (4872 participants) in primary care settings demonstrated strong evidence that patient education reduces psychological distress and healthcare utilization related to low-back pain. Despite these benefits, patient education alone did not improve pain levels or function in acute low-back pain cases.
Other nonpharmacologic options suggested by the US guideline for initial management include superficial heat and acupuncture. The evidence review for the guideline indicated low-quality evidence (two RCTs, 100 participants) for a small short-term pain relief effect from acupuncture compared to placebo acupuncture. This contrasts with the UK guideline, which advises against offering acupuncture for low-back pain due to a lack of “compelling and consistent treatment-specific effect.” The UK guideline acknowledges some studies showing clinically relevant effects compared to standard care but points out these were short-term studies potentially influenced by contextual factors, such as patient expectations or the effects of reassurance and emotional support. Superficial heat therapy received endorsement from the US guideline based on a Cochrane review. This review found moderate-quality evidence (two RCTs, 258 participants) for a moderate short-term pain relief effect (around 17 points on a 100-point scale) compared to oral placebo or non-heated wraps.
The US guideline analysis of exercise for acute low-back pain revealed low-quality evidence (six RCTs: three from a 2005 Cochrane review [491 participants] and three additional trials [653 participants]) indicating exercise is not effective compared to usual care. However, the role of exercise in preventing pain recurrence after recovery was examined in a systematic review of 21 RCTs (30,850 participants). This review concluded that there was low- to very low–quality evidence that exercise alone could reduce the risk of future low-back pain episodes compared to no exercise (relative risk [RR] 0.65, 95% confidence interval [CI] 0.50–0.86).
Pharmacologic Treatment Options
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the only pharmacologic treatment endorsed by both the recent US and UK guidelines as of 2017. A systematic review with high-quality evidence (five randomized trials, 814 participants) showed that NSAIDs provide a small pain-relieving effect compared to placebo in acute low-back pain (mean difference 6.4 points on a 100-point scale, 95% CI 2.5–10.3). The risks associated with NSAIDs are well-documented. The US guideline identified moderate-quality evidence (10 RCTs) for an increased risk of adverse events like abdominal pain, gastrointestinal bleeding, and heartburn (RR 1.35, 95% CI 1.09–1.68). Consequently, pharmacologic options are considered second-line treatments. Besides NSAIDs, skeletal muscle relaxants are also considered as a possible option.
A review assessing the effectiveness and tolerability of muscle relaxants found good-quality evidence (five RCTs, 496 participants) that these medications offer clinically significant pain relief in acute low-back pain (approximately 20 points on a 100-point scale) compared to placebo. However, the US guideline cited evidence from eight RCTs indicating increased risks of dizziness, drowsiness, and sedation (RR 1.50, 95% CI 1.14–1.98) with muscle relaxants. These potential harms are particularly important to consider when prescribing muscle relaxants to specific patient groups, such as older adults.
Disclaimer: This information is for educational purposes and should not be considered medical advice. Always consult with a healthcare professional for diagnosis and treatment of medical conditions.
