Recent updates to clinical guidelines have significantly shifted the approach to managing acute low-back pain. Notably, current recommendations emphasize non-pharmacological interventions as the primary strategy, moving away from initial reliance on drug-based pain relief. Furthermore, the UK guidelines now advocate for a stratified management approach, utilizing prognostic screening questionnaires to guide treatment decisions rather than solely relying on the patient’s initial response to therapy. Guideline-consistent management strategies for acute low-back pain are summarized in Table 1. The evolution of low-back pain management over the last decade is further detailed in Appendix 2 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170527/-/DC1).
Table 1: Recent Guideline Recommendations for Managing Acute Nonspecific Low-Back Pain
| Type | Intervention | Size of effect* | Quality of evidence* | Guideline Endorsement |
|---|---|---|---|---|
| 2016 UK guideline14 | 2017 US guideline15 | |||
| Nonpharmacologic | Advice to stay active v. bed rest | Small | Moderate† (2 RCTs)35 | Yes |
| Massage v. sham treatment | Moderate | Low (2 RCTs) | Yes, if part of an exercise program | |
| Spinal manipulation v. inert treatment | No effect | Low (3 RCTs) | Yes, if part of an exercise program | |
| Acupuncture v. sham treatment | Small | Low (3 RCTs) | Do not offer | |
| Heat v. sham treatment | Moderate | Moderate (4 RCTs) | No mention | |
| Exercise v. usual care | No effect | Low (6 RCTs) | Yes | |
| Psychologically informed physiotherapy v. usual care | No trials | N/A† | Yes, for those at high risk of poor outcome | |
| Pharmacologic | NSAIDs v. placebo | Small | Moderate (5 RCTs) | Yes |
| Muscle relaxants v. placebo | Small | Moderate (5 RCTs) | No mention | |
| Opioids v. placebo | No trials | N/A† | Yes, if NSAIDs are unsafe or ineffective; weak opioid only | |
| Paracetamol v. placebo | No effect | High† (2 RCTs)36 | Do not offer | |
| Systemic corticosteroids v. placebo | No effect | Low (2 RCTs) | No mention |
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 Approaches to Low-Back Pain Management
Current guidelines strongly advocate for nonpharmacologic treatments as the first-line approach for acute low-back pain. A cornerstone of this approach is advising patients to remain active and providing reassurance about the generally favorable prognosis and low likelihood of serious underlying conditions. It is also beneficial to inform patients about the common occurrence of low-back pain recurrence.
While options such as massage and spinal manipulation are considered within nonpharmacologic treatments, it’s important to note the qualification from the US guideline that “most patients with acute or subacute low back pain improve over time regardless of treatment.” Acute episodes typically show rapid improvement within the initial two weeks. Therefore, scheduling a follow-up appointment within one to two weeks of the initial consultation is recommended to assess recovery progress and the effectiveness of any implemented treatments. This timely review allows for adjustments to the management plan as needed.
Evidence supporting spinal manipulation for acute low-back pain, as evaluated for the US guidelines, was considered limited. Two Randomized Controlled Trials (RCTs) involving 292 participants indicated a small effect on function and an uncertain effect on pain compared to placebo spinal manipulation. However, a more recent systematic review encompassing 15 RCTs (1711 participants) presented moderate-quality evidence suggesting that while spinal manipulation was not superior to placebo spinal manipulation for pain reduction, it was associated with a minor short-term pain reduction compared to other treatments (approximately 10 points on a 100-point scale). It’s also important to consider that spinal manipulation has been reported to cause short-term pain increase in 50% to 67% of patients.
Patient education plays a significant role in managing low-back pain. A systematic review of 14 RCTs (4872 participants) focused on patient education interventions in primary care demonstrated strong evidence of reduced psychological distress and decreased healthcare utilization related to low-back pain. However, patient education alone did not show improvement in pain or function in patients experiencing acute low-back pain.
Other nonpharmacologic options suggested by the US guideline for initial management include superficial heat and acupuncture. The evidence review for the US guideline indicated low-quality evidence (two RCTs, 100 participants) for a small short-term pain reduction with 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 usual care but points out their short-term nature and potential contextual effects, such as positive patient expectations and the impact of reassurance and emotional support. Superficial heat therapy received endorsement from the US guideline based on a Cochrane review, which provided moderate-quality evidence (two RCTs, 258 participants) for a moderate effect (around 17 points on a 100-point scale) on short-term pain relief compared to oral placebo or nonheated wraps.
Regarding exercise, the US guideline found low-quality evidence (six RCTs: three from a 2005 Cochrane review [491 participants] and three additional trials [653 participants]) suggesting that exercise is not effective for acute low-back pain compared to usual care. However, exercise does play a role in preventing pain recurrence after recovery. A systematic review of 21 RCTs (30,850 participants) concluded that there is low- to very low-quality evidence that exercise alone can 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 Options for Low-Back Pain Management
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the primary pharmacologic agents endorsed by both recent guidelines for managing acute low-back pain. A systematic review has shown high-quality evidence (five randomized trials, 814 participants) that NSAIDs provide a small but statistically significant effect on pain compared to placebo in patients with acute low-back pain (mean difference 6.4 points on a 100-point scale, 95% CI 2.5–10.3). However, the risks associated with NSAIDs are well-documented. The US guideline identified moderate-quality evidence (10 RCTs) indicating an increased risk of adverse events such as abdominal pain, gastrointestinal bleeding, and heartburn (RR 1.35, 95% CI 1.09–1.68). Therefore, pharmacologic options are recommended as second-line treatments, with NSAIDs and skeletal muscle relaxants being considered.
A review evaluating the efficacy and tolerability of muscle relaxants found good-quality evidence (five RCTs, 496 participants) that these medications offer clinically meaningful pain relief in patients with acute low-back pain (approximately 20 points on a 100-point scale) compared to placebo. However, the US guideline also highlights potential harms associated with muscle relaxants, based on evidence from eight RCTs, including an increased risk of dizziness, drowsiness, and sedation (RR 1.50, 95% CI 1.14–1.98). These side effects are particularly important to consider when prescribing muscle relaxants for specific patient populations, such as older adults.
