How to manage an episode of low back pain?

---

A paradox

Nearly everyone experiences at least an episode of low back pain in their life (acute low back pain). Acute low back pain can cause substantial suffering and physical impairments, and is associated with very high social costs due to missing work days and use of healthcare. Despite the enormous frequency and social importance of acute low back pain, we know almost nothing about its causes, and there are hardly treatments that have been proven to be effective by rigorous research.

What causes acute low back pain?

Although patients are frequently provided with an explanation for their pain and a treatment plan, most diagnoses are based on hypotheses, and most treatments are unproven. Let's consider the example of "muscle tension", which is frequently provided as an explanation for acute low back pain. This diagnosis is based on the finding of tense/painful spots of the back. However, the tense/painful spots on the back may not be the source of the pain, and the causes of the muscle tension are unknown. Massage, manipulation, or local injections may be recommended to treat the muscle tension. If these treatments help, one may conclude that the problem was indeed in the muscle, and the treatments were effective. However, these conclusions are not necessarily correct.

Having improved "after" a treatment does not necessarily mean having improved "because of" the treatment

Most people with acute low back pain recover within a few weeks, regardless of the treatment they receive. In a very recent study, the likelihood of recovery was 70% before 1 week, 86% before 3 weeks, 91% before 6 weeks, and 93% before 12 weeks. This suggests that the natural course of acute low back pain is favorable and that the effect of any given treatment may be minimal.

Which treatments work?

A comprehensive discussion on treatments is outside the scope of this blog, but let's consider medications. A recent large systematic review has pooled together the results of 98 studies that included 15,134 patients, treated with 69 different medications or combinations of medications. The study found very modest evidence for the superiority of medications over placebo or of a medication over another.

The use of anti-inflammatory drugs, such as ibuprofen or diclofenac, is common and easy to access. However, a recent investigation has shown that taking these drugs during the acute stage of low back pain may increase the risk of developing chronic low back pain. This unexpected effect may be due to the role of inflammation in repairing damaged tissues; blocking this process may prevent proper healing, and thus prolong the pain.

There are many other options for treating acute low back pain, such as massage, manipulation, physical therapy, and more, but none of them are clearly and significantly better than letting the pain resolve naturally. When back pain is associated with leg pain due to spinal nerve pathology (radicular pain), epidural injections may be recommended. These injections can provide short-term relief, which can be helpful when the pain is unbearable. However, they are not likely to have long-term benefits (read more here).

Should opioids been prescribed?

Opioids are not effective for acute low back and neck pain, according to a new high-quality study. The study randomly assigned patients to receive either an opioid or a placebo. Neither the patients nor the researchers who assessed the outcomes knew which treatment was given. The results showed no difference between the opioid and the placebo groups, suggesting that opioids should not be prescribed for these conditions.

However, the results apply to the specific study conditions, which were in part peculiar. For example, a special formulation that releases the opioid slowly over 12 hours was administered twice a day. In most clinical situations, acute pain is treated typically as needed, and using rapid-release opioids.

Since we know so little, what should we do?

There is a very high chance of recovering from acute low back pain. Some people may experience anxiety and fear about their back health. Research has shown that these negative emotions are risk factors for chronic pain.

The most important treatment is reassure that time will lead to recovery

Most people do not need to seek professional help. Tests and specialized treatments are not indicated in the large majority of cases, and will cause costs with questionable benefits. For example, studies have shown that getting an MRI or other scans in this stage lead to more procedures, such as injections or surgery, without improving the long-term outcome. So, getting an MRI may do more harm than good (read more here).

Prioritize self-management:

• If back pain is the only symptom, do not seek professional care for the first 2 weeks, or longer if there is a gradual improvement

• Avoid diagnostic tools, such as MRI

• Moderate and intermittent physical activity is important; avoid prolonged rest

• Medication management should not be aggressive, and primarily based on acetaminophen/paracetamol, if not contraindicated

• Avoid or use restrictively anti-inflammatory medications, as they may make your pain last longer

• Avoid opioids, as they are not likely to work and may cause harm

• You can try non-pharmacological and non-invasive treatments such as massage or acupuncture, knowing that it is unclear whether they will facilitate the recovery, as compared with waiting for spontaneous resolution.