Preloader Icon
Back pain - low (without radiculopathy)
September 4, 2019

Back pain - low (without radiculopathy)

Back pain - low (without radiculopathy)

Scenario: Management

From age 16 years onwards.

  • If there are Red flag symptoms and signs that may suggest a serious underlying cause, admit or refer urgently for specialist assessment, or imaging, using clinical judgement.
  • If an underlying cause for the low back pain has been identified, manage according to the specific diagnosis. 
  • If non-specific low back pain is suspected, assess the person using a risk stratification tool such as STarT Back to identify modifiable risk factors (biomedical, psychological and social) for back pain disability.
  • Quality of life, pain severity, function, and psychological distress are the most important factors to guide the person's management.
  • People with low back pain who are likely to improve quickly generally need less intensive support, while people at higher risk of a poor outcome may require more complex and intensive support.
  • For all people with non-specific low back pain:
  • Offer Self-management advice, tailored to the person's needs and capabilities, including information on the nature of low back pain, and encouragement to continue with normal activities.
  • Offer analgesia to manage pain:
  • Offer a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen first-line, if there are no contraindications. An NSAID should be used at the lowest effective dose for the shortest possible time. Gastroprotective treatment should also be offered while an NSAID is being used.
  • If an NSAID is contraindicated, not tolerated, or ineffective, offer codeine with or without paracetamol, taking into account the risk of opioid dependence and adverse effects such as constipation. 
  • Do not offer paracetamol alone for managing low back pain.
  • For information on prescribing analgesics, see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
  • If the person has muscle spasm, consider offering a short course of a benzodiazepine, such as diazepam 2 mg up to three times a day for up to 5 days, if not contraindicated.
  • For more information on prescribing diazepam, see the prescribing information section on Diazepam.
  • Advise the person to seek follow-up if symptoms persist or are worsening after 3–4 weeks.
  • For people assessed at higher risk of a poor outcome:
  • Offer referral for a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches). Take the person's specific needs, preferences and capabilities into account when choosing the type of exercise.
  • Consider offering referral to a physiotherapist for manual therapy (spinal manipulation, mobilisation, or massage) as part of a treatment package including exercise.
  • Consider offering referral for cognitive behavioural therapy as part of a treatment package including exercise, with or without manual therapy, if the person has significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition), or when other treatments have not been effective.
  • Promote and facilitate return to work or normal activities of daily living.

The STarT Back Screening Tool

  • The  Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability.
  • The resulting score stratifies patients into low, medium or high-risk categories.
  • For each category there is a matched treatment package.
  • This approach has been shown to reduce back pain related disability and be cost-effective.

Offering benzodiazepines for muscle spasm

  • The recommendation to consider offering a benzodiazepine such as diazepam if there is muscle spasm is based on expert opinion in the US clinical guideline Adult acute and subacute low back pain published by the Institute for Clinical Systems Improvement [ICSI, 2012], which notes that historically muscle relaxants have been recommended on the basis of evidence from trials on the management of non-specific low back pain (without radiculopathy). This guideline states that muscle relaxants may be an option in treating acute low back pain, taking into account their adverse effect profile.
  • The literature is conflicting however, and the University of Michigan Health System guideline states there is no evidence to support their use over other treatments such as NSAIDs [University of Michigan Health System, 2010]. NICE currently states that 'the evidence base to support use of this particular medicine (diazepam as a muscle relaxant in the treatment of lower back pain) is extremely small. Benzodiazepines are not without risk of harm, even for short-term use. Because of this, there is a need to find out if diazepam is clinically and cost effective in the management of acute low back pain' [NICE, 2016b].
  • In the UK, diazepam is the only benzodiazepine licensed for acute pain associated with muscle spasm [BNF 72, 2016].
  • The information on arranging follow-up is based on expert opinion in a narrative review article [Chou, 2014].
  • Because most people with uncomplicated low back pain improve over 2-4 weeks [Chou, 2014], follow-up can be patient-led depending on need. However, the person should be advised to seek follow-up if symptoms have not improved or are worsening after 3-4 weeks to further rule out an underlying pathology and as they are then at risk of developing chronic back pain [Chou, 2014].

Self-management advice

  • Address any specific concerns the person has about the cause of their pain and their expectations of treatment. In general advise them that:
  • Acute non-specific low back pain is not caused by serious structural damage.
  • Most people can reasonably be expected to recover from an episode of acute non-specific back pain within a period of weeks.
  • Provide information on self-help measures to relieve symptoms.
  • Offer information leaflets on simple exercises that may help relieve symptoms, for example Exercises for a better back provided by the charity Backcare, which has a range of information leaflets available at www.backcare.org.uk.
  • Local heat (ensuring that the skin is protected) may relieve pain and muscle spasm.
  • Encourage the person to stay active, resume normal activities, and return to work as soon as possible. Advise that:
  • Prolonged bed rest is not recommended, and that normal movements may produce some pain which should not be harmful if activities are resumed gradually and as tolerated.
  • The person does not need to be pain-free before returning to normal activities or work. Work adjustments can make an early return to work possible; this may be arranged by an Occupational Health department if available.
  • Keeping as active as possible and exercising regularly is important to reduce the risk of recurrence.

Basis for recommendation

The recommendation to provide self-management advice to people with low back pain, including information on the nature of low back pain, encouragement to continue with normal activities, and facilitating return to work, is largely based on expert opinion in the National Institute of Health and Care Excellence (NICE) guideline Low back pain and sciatica in over 16s: assessment and management [NICE, 2016b].

Application of heat

  • The recommendation on application of heat for short-term relief of acute low back pain is based on expert opinion in several US clinical practice guidelines such as Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [Chou et al, 2007], Acute low back pain published by the University of Michigan Health System [University of Michigan Health System, 2010], and Adult acute and subacute low back pain published by the Institute for Clinical Systems Improvement [ICSI, 2012].

Exercise, activities, and work

  • The recommendation on exercise is based on expert opinion in clinical guidelines Acute low back pain published by the University of Michigan Health System [University of Michigan Health System, 2010] and Adult acute and subacute low back pain published by the US Institute for Clinical Systems Improvement [ICSI, 2012].
  • The University of Michigan guideline recommends back core strengthening exercises and aerobic exercises which minimally stress the back, for example walking, cycling, or swimming [University of Michigan Health System, 2010].
  • The Institute for Clinical Systems Improvement recommends using a 'core treatment plan' for all people with acute and subacute low back pain, but does not specify a particular type of exercise [ICSI, 2012].
  • The recommendations to avoid bed rest for any longer than is needed and the resumption of normal activities are based on expert opinion in several international clinical guidelines such as Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [Chou et al, 2007], Acute low back pain published by the University of Michigan Health System [University of Michigan Health System, 2010], Adult acute and subacute low back pain published by the US Institute for Clinical Systems Improvement [ICSI, 2012], and Guideline for the evidence-informed primary care management of low back pain published by a Canadian guideline group [Toward optimized practice, 2015].
  • The Institute for Clinical Systems Improvement recommends encouraging activity and exercise within the limits permitted by the person's symptoms. It stresses the importance of addressing fears and beliefs that activity will increase pain and/or cause harm. Exploring these beliefs helps prevent a fear of disability becoming a barrier to clinical improvement. In addition, staying active and continuing normal activities as tolerated ensures a faster return to work, reduces the risk of long-term physical impairment, and reduces the risk of recurrent back pain [ICSI, 2012].
  • The recommendations regarding encouraging an early return to work are based on expert opinion in US clinical guidelines Acute low back pain published by the University of Michigan Health System [University of Michigan Health System, 2010] and Adult acute and subacute low back pain published by the Institute for Clinical Systems Improvement [ICSI, 2012].
  • The University of Michigan Health System guideline suggests that workplace modifications can improve return to work rates and decrease the duration of functional impairment [University of Michigan Health System, 2010].
  • The Institute for Clinical Systems Improvement recommends that people can return to work before they are pain-free, as complete pain relief often occurs after resumption of normal activities. It also recommends that employers should provide modified duties or activities to allow an early return to work and minimize the risk of prolonged functional impairment [ICSI, 2012].
  • Several clinical guidelines recommend the use of physical activity and exercise to manage, and reduce the risk of recurrence of, back pain [University of Michigan Health System, 2010; ICSI, 2012; Toward optimized practice, 2015; NICE, 2016b].
Back to Blogs