Musculoskeletal lower back pain

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The main treatment aims are to reduce pain and restore functional status.

Nonpharmacologic interventions should be tried first for acute, subacute, chronic, and recurrent lower back pain.[82] For patients with an inadequate response to nonpharmacologic interventions, pharmacotherapy is recommended as an adjunct treatment.[82]

Consideration should be given to referring patients with musculoskeletal lower back pain to a psychiatrist or a psychologist if suspected of having major depression or anxiety.

Patient education

Patient education is recommended as part of initial treatment for all patients with low back pain and serves as the framework for management.[83] Patient education should emphasize the overall favorable prognosis of nonspecific lower back pain and the high risk of recurrence.

No further treatment may be needed, especially in patients who are at low risk of developing chronic back pain. However, patient education alone has been demonstrated as effective in the short term, but should be used in combination with other interventions if required to prolong and improve beneficial patient outcomes.[84]

Patient education has been shown to improve pain and function in older people with lower back pain, but other evidence suggests that it makes little to no difference in pain and function compared with placebo for patients with acute and/or subacute lower back pain.[85][86] However, when the effects on other outcomes, such as reassurance, and the patient’s wish for information are considered, patient education should be part of first-line treatment.[86]

Clinicians should reassure patients that resuming ordinary daily activities is extremely unlikely to result in aggravation of lower back pain or any serious injury to their back and encourage return to usual activity as soon as possible. One Cochrane review found that advice to remain active is associated with small improvements in pain and functional status compared with bed rest.[87]

Nonpharmacologic treatment: acute and subacute lower back pain

Given the favorable prognosis of acute and subacute musculoskeletal lower back pain, initial treatment with nonpharmacologic intervention is recommended.[82]

For patients with acute and subacute lower back pain, superficial heat, massage, acupuncture, and spinal manipulation are recommended as adjunct treatments.[82]

Self-care temperature treatments for acute and subacute lower back pain

Evidence to support superficial heat and cold for lower back pain is limited. One Cochrane review concluded that there is moderate evidence to support the use of heat-wrap therapy for short-term reductions in pain and stiffness in acute and subacute lower back pain compared with oral placebo.[88] The addition of exercise further reduced pain and improved function.

Evidence of benefit for the use of ice for people with lower back pain is limited to poor-quality studies, with the Cochrane review reporting that no conclusions can be drawn on its efficacy.[88] However, in practice, ice reduces pain in many patients, especially within the first few days of pain onset. Given its favorable risk-benefit profile (associated adverse events such as frostbite are rare), ice may be considered as a potential treatment.

Massage for acute and subacute lower back pain

There is low-quality evidence to suggest that massage may improve short-term pain in people with subacute lower back pain.[89] However, no improvement in function was reported.[89]

Acupuncture for acute and subacute lower back pain

One Cochrane review concluded that acupuncture may have no clinically meaningful role in relieving pain immediately after treatment or in improving quality of life in the short term, and possibly did not improve function compared to sham acupuncture in the immediate term for people with acute lower back pain.[90] In comparison to usual care, an improvement was demonstrated in function and quality of life, but no reduction in pain was reported immediately after the acupuncture session. However, in comparison to no treatment, acupuncture improved pain and function in the immediate term.[90]

The results of subsequent systematic reviews varied.[91][92] Compared with a control treatment, acupuncture reduced pain, and the number of pills taken for people with acute lower back pain in one meta-analysis.[92] The study reported that conclusions should be viewed with caution due to the low power of the included studies.[92] A further network meta-analysis found that acupuncture reduced pain compared with placebo and improved function compared with pharmacotherapy; however, the quality of the included trials was poor.[91]

Spinal manipulation for acute and subacute lower back pain

A wide variety of spinal manipulation techniques can be performed, all involving the manual movement of the spine to achieve a therapeutic effect. Practitioners such as physicians, chiropractors, and physical therapists have different training, so manipulation techniques are heterogeneous. There is no evidence showing superior results for one type of spinal manipulation over another.

One meta-analysis reported that spinal manipulation therapy was no more effective for acute lower back pain than sham spinal manipulation therapy, inert intervention, or other recommended therapies.[93] A subsequent randomized controlled trial found that spinal manipulation therapy was associated with a significant reduction in pain and disability scores after 4 weeks, compared with usual medical care. However, pain and functional scores at 3 months and 6 months were not significantly different between the groups.[94]

The risks of lumbar spinal manipulation are low and severe adverse events such as cauda equina syndrome and disk herniation are rare.[95] Increased short-term back pain and discomfort following manipulation is a frequent adverse effect.[96][97] There is evidence to suggest that the optimum number of treatments is 12, with anything over 18 giving no extra benefit.[98]

Physical therapy and exercise for acute and subacute lower back pain

Referral for active physical therapy or exercise therapy should be considered, particularly in patients who have had low back pain for >6 weeks. Early referral to physical therapy may result in a reduced risk of advanced imaging, opioid use, surgery, and spinal injections compared with delayed physical therapy.[99][100]

The results of systematic reviews on the efficacy of exercise are conflicting. Some data suggest that exercise interventions improve muscle strength, endurance, and electrical activity in people with nonspecific low back pain compared with active or passive control.[101] However, one meta-analysis that only included people with acute lower back pain concluded that there is very low to moderate certainty of evidence that exercise therapy results in little or no important difference in pain or disability, compared with other interventions, in adult patients.[102]

Subsequent systematic reviews suggest that effective exercise interventions for people with lower back pain include trunk-focused exercise (including hip strengthening exercises) and resistance training.[103][104][105][106] A small benefit may also be seen by adding pelvic floor exercises to the regimen, but this is based on very low-quality evidence.[107] However, these studies were not exclusively in people with acute lower back pain.

Pharmacotherapy: acute and subacute lower back pain

Pharmacotherapy can be considered as an adjunct in acute and subacute low back pain after discussing the risks and benefits with the patient.[82]

Analgesics for acute and subacute lower back pain

First-line medications include a short course of a nonsteroidal anti-inflammatory drug (NSAID), at the lowest possible dose, in patients with no significant gastric, cardiovascular, or renal comorbidities.[81] [ ] Evidence suggests that NASIDs may be slightly more effective at reducing short-term pain, disability, and global improvement for people with acute low back pain, compared with placebo.[108]

Acetaminophen alone is not recommended for acute lower back pain.[81] There is high-quality evidence to indicate that acetaminophen is no more effective than placebo for the management of acute low back pain.[109][110] [ ] However, in practice, if there are contraindications to NSAIDs, a short course of acetaminophen may be considered, provided there are no hepatic comorbidities. The combination of NSAIDs and acetaminophen has been demonstrated to reduce disability, compared with NSAIDs alone, in people with acute lower back pain.[111]

Opioids for severe acute low back pain

In practice, a short course of tramadol or another opioid such as codeine or oxycodone may be considered if acute lower back pain is severe and uncontrolled despite a return to normal activities, self-care treatments, and initial pharmacotherapy. The ongoing requirement for opioids should be in accordance with guidelines and the risks and benefits should be discussed with the patient.[112]

One placebo-controlled, randomized trial found no significant difference between opioids, compared with placebo, for pain severity for people with acute lower back pain presenting to primary care or the emergency department.[113] Adverse effects were more common in the opioid group.

Short-term adverse effects may include increased nausea, dizziness, constipation, vomiting, somnolence, or dry mouth. Longer-term risks include addiction, misuse, or overdose.[82]

Muscle relaxants for acute lower back pain

A short-term course of a muscle relaxant may be considered in patients with acute and subacute low back pain.[82]

There is very low and low certainty evidence that muscle relaxants reduce acute lower back pain before 2 weeks compared with placebo or control; however, the benefit is small and may not be clinically important and their use may be associated with an increased risk of adverse events.[114][115] The most common adverse effect is drowsiness, which can limit their use during the daytime.

There is some evidence suggesting that the combination of muscle relaxants and either acetaminophen or an NSAID leads to improved outcomes compared with either alone.[114][116] Some muscle relaxants are potential drugs of abuse; therefore, benzodiazepines should not be used as first-line agents.

Nonpharmacologic treatment: chronic back pain

Nonpharmacologic therapies are recommended first-line for patients with chronic lower back pain.[82]

Physical therapies for chronic back pain

Recommended physical therapies include exercise therapy, active physical therapy, pilates, tai chi, yoga, motor control exercise, low-level laser therapy, acupuncture, and spinal manipulation for people with chronic low back pain.[82] Physical therapists may elect to use modalities such as ice, heat, and ultrasound.[117] [ ] These should be adjunctive to active exercise therapy.

Physical and exercise therapy for chronic low back pain

Studies on exercise therapy vary in terms of frequency, duration, physical therapist guidance or instruction, and specific maneuvers performed. There is no definitive evidence to suggest that certain exercises or routines are superior to others.[118] Data from systematic reviews demonstrate a small but beneficial effect on pain and function in people with chronic low back pain compared with no treatment, usual care, conservative treatment, or placebo.[119][120] The benefit of exercise therapy may be more pronounced in older adults with chronic low back pain, but the elements of the exercise therapy should be carefully considered to ensure patient safety.[121]

Group exercise may be considered for people with chronic lower back pain.[82][81][Evidence C] One cluster randomized controlled study suggests that group therapy is as effective as individualized treatment.[122]

Exercise frequency may be more important than the type, duration, or intensity of exercise (in patients with recurrent low back pain).[123] Early physical therapy seems to be associated with reduction in likelihood of opioid use among patients with low back pain and reduction in oral morphine milligram equivalents among patients who did use opioids.[99]

Most back-exercise programs target strengthening of core muscles (abdominals, obliques, erector spinae, pelvic floor muscles, and latissimus dorsi), aerobic conditioning, and spine flexibility in extension, flexion, lateral bending, and rotation.

Effective exercise interventions for people with chronic low back pain include core stability exercise (including walking, swimming, and cycling), strength and resistance exercises, coordination/stabilization exercise programs.[120][124][125][126][127][128][129]

Aquatic therapy may be as beneficial as land-based exercise.[130] Results of one meta-analysis demonstrated that aquatic therapy reduced pain intensity, improved quality of life, and reduced disability, but did not improve pain at rest for people with chronic lower back pain, compared with the control group.[131]

Pilates, tai chi, and yoga for chronic low back pain

There is evidence to suggest that pilates, yoga, and tai chi may reduce pain and improve function in people with chronic lower back pain.[132][133][134][135]

Compared with nonexercise, yoga may result in small, but clinically unimportant, improvement in back related function and pain.[136] It remains unclear if yoga is more effective at reducing pain and improving function compared with exercise or physical therapy control groups.[137][138]

Pilates may be more effective than general exercise or control as an intervention for chronic lower back pain, but evidence suggests that it is not more effective at reducing pain and improving function than other forms of direction-specific exercise and spinal stabilization exercise.[139][140]

Motor control exercise for chronic low back pain

This therapy focuses on activation of the deep trunk muscles and aims to restore the coordination, control, and strength of these muscles.

There is very low to moderate evidence that motor control exercises have a clinically important effect on pain and function for people with chronic lower back pain compared with minimal interventions.[141] Similar results have been demonstrated with moderate- to high-quality evidence when motor control exercises are compared with manual therapy, and low-quality evidence suggests similar results compared with other exercises.[141]

A subsequent systematic review including low to very low-quality evidence demonstrated that motor control exercises reduce pain and improve function compared with a sham control, and reduced pain compared with other treatments for nonspecific chronic low back pain at 6 months.[142] However, similar effects on pain reduction were reported at the 12-month and 24-month follow-up period, and on disability at the 6-month, 12-month and 24-month follow-up period.[142]

Acupuncture for chronic low back pain

Acupuncture is widely accessed by patients with chronic lower back pain. It is unclear whether it is an effective treatment as evidence from systematic reviews have conflicting results.[143][144]

Some evidence suggests that acupuncture is more effective than no treatment or sham treatment for immediate and short-term pain relief in patients with nonspecific chronic low back pain.[143][144] Conversely, one Cochrane review concluded that acupuncture may not play a clinically meaningful role in relieving pain immediately after treatment, improve quality of life in the short term, and may not improve back function in the immediate term compared with sham control in people with chronic lower back pain.[90]

Spinal manipulation therapy for chronic low back pain

Systematic review evidence demonstrates that both mobilization and spinal manipulation therapy are beneficial for treatment of lower back pain in the short term, but no one type of spinal manipulation is superior over another.[145][146][147]

High-quality evidence indicates that spinal manipulation therapy is not more effective than other interventions for reducing pain and improving function in people with chronic lower back pain.[148][149] However, there is low-quality evidence that implies that osteopathic manipulation therapy is more beneficial at pain reduction and in changing functional status, compared with control interventions.[150]

One study concluded that the optimum number of effective treatments is 12, with anything over 18 giving no additional benefit.[98]

The risks of lumbar spinal manipulation are low, especially in comparison with cervical manipulation. Severe adverse events such as cauda equina syndrome and disk herniation are rare.[95] Increased short-term back pain and discomfort after manipulation is a frequent adverse effect.[96][97]

Massage for chronic low back pain

Massage therapy may improve pain and function in people with chronic lower back pain compared with inactive controls, but only in the short term.[89] [ ] However, included trials were of low quality.

Low-level laser therapy for chronic low back pain

Low-level laser therapy (LLLT), also known as photobiomodulation, is a low-intensity light treatment that triggers intracellular biochemical changes. Light with a wavelength in the red to near-infrared region of the electromagnetic spectrum is able to penetrate skin and soft tissues. This affects the cells through multiple mechanisms: dissociation of nitric oxide from cytochrome c oxidase; light-mediated vasodilatation; increasing reactive oxygen species and decreasing reactive nitrogen species; and activating transcription factors for genes encoding growth factors.[151]

Low-level laser has been demonstrated to significantly reduce pain compared with control in people with chronic lower back pain at 30 months.[152]

Behavioral therapies for chronic low back pain

Behavioral therapies may include mindfulness-based stress reduction, progressive relaxation, cognitive behavioral therapy (CBT), operant therapy, and electromyographic biofeedback.[82] Behavioral therapies can help the patient to acknowledge that external factors associated with pain can reinforce it, help patients to manage thoughts, feelings, and beliefs that trigger pain; and interrupt muscle tension (e.g., using progressive relaxation techniques or electromyographic biofeedback).[153]

Psychosocial assessment should form part of the evaluation of lower back pain. Psychiatric comorbidities such as depression, anxiety, and somatization increase the risk of progression to chronic disabling pain.[62] Risk factors for worst outcomes at 1 year include maladaptive pain-coping behavior, nonorganic signs, functional impairment, poor general health, and the presence of psychiatric comorbidities.[34]

No one behavioral therapy is more effective than another.[153] Compared with waiting list control or usual care operant therapy and behavioral therapy respectively are more effective at reducing pain for people with chronic low back pain.[153] Low-quality evidence suggests that progressive relaxation is more effective at improving short-term function, and that electromyographic biofeedback is more effective at reducing short-term pain relief compared with waiting list control.[153]

CBT has been demonstrated to improve pain, disability, fear avoidance, and self-efficacy compared with control groups (waiting list/usual care, active therapy).[154] CBT may be effective when delivered in a group setting or online.[155][156][157][158][159]

Mindfulness-based stress reduction and CBT are equally effective at improving pain and functional limitations in adults with chronic low back pain.[160] Both are more effective than usual care.[160] A subsequent systematic review found that when compared with cognitive behavioral therapy, usual care or wait list control, mindfulness based stress reduction improved physical function at 8 weeks and 6 months follow-up in people with chronic lower back pain.[161]

Low-quality evidence suggests that respondent therapy (progressive relaxation or electromyogram biofeedback) is more effective than a waiting list control for short‐term pain relief, but there was no effect upon function.[153]

Multidisciplinary rehabilitation for chronic low back pain

Multidisciplinary rehabilitation combines physical and psychological therapies, and is recommended for people with persistent low back pain who may have psychosocial obstacles to recovery, e.g., avoiding normal activity based on inappropriate beliefs about their condition.[82][81] Individualizing rehabilitation therapy has been demonstrated to be more effective than other active treatments in people with chronic lower back pain.[162]

Evidence from Cochrane reviews suggest that multidisciplinary biopsychosocial rehabilitation (MDR) reduces pain and disability compared with usual care or physical treatment in people with chronic or subacute low back pain.[163] [ ] A subsequent meta-analysis reported that MDR is more effective at reducing pain and disability compared with other rehabilitation interventions for people with chronic low back pain, but is not more effective for people with acute low back pain.[164]

The addition of CBT to routine physical therapy appears to reduce pain and disability, and improve functional capacity, compared with physical therapy alone.[165]

Pharmacotherapy: chronic lower back pain

Patients with chronic low back pain who have an inadequate response to nonpharmacologic treatment should be offered pharmacotherapy.[82]

Analgesia for chronic low back pain

NSAIDs are recommended first-line treatment. Second-line treatment may include tramadol or duloxetine.[82] There is some evidence to suggest that combination pharmacotherapy is more effective for people with chronic low back pain.[166]

Duloxetine (a serotonin-norepinephrine reuptake inhibitor [SNRI]) is the only antidepressant recommended for people with chronic low back pain and can be considered as second-line treatment in the US, but is not recommended in the UK.[81][82][167]

There is moderate- to high-quality evidence that duloxetine can reduce pain and improve function for adults with chronic pain (including musculoskeletal pain).[168] [ ] Earlier systematic reviews specific to back pain reported moderate evidence that the effect of SNRIs on pain and disability scores is small and not clinically important.[169][170]

Opioids other than tramadol may be considered as a third-line option for patients with chronic low back pain who have not responded to other treatments, if the potential benefits outweigh the risks and after discussing the risks and benefits with the patient.[82] For people with chronic lower back pain, there is very low- to high-quality evidence that opioids may have a small beneficial effect on pain.[171] However, this benefit may only be seen in the short or intermediate term (4-15 weeks), long-term effects of opioids (≥6 months) may not be superior to nonopioids in improving pain or disability or pain-related function in people with chronic lower back pain, and are associated with more adverse effects, opioid misuse or dependence, and possibly an increase in all-cause mortality.[172]

Opioids should be considered for short- to medium-term treatment of carefully selected patients with chronic nonmalignant pain and only continued if effective.[167] Regular review is required, at least annually. [ ] Specialist referral or advice should be considered if there are concerns about rapid dose escalation, or the dose exceeds 90 mg/day morphine equivalent.[167]

Recurrence

It is unclear why acute nonspecific lower back pain recurs so often. The threshold for investigation in this patient group is often low.

The treatment approach is the same as the treatment of acute nonspecific lower back pain, provided there are no red flags: recent significant trauma; minor fall or heavy lift in a potentially osteoporotic or elderly person; unexplained weight loss; immunosuppression; history of cancer; intravenous drug use; prolonged use of corticosteroids; urinary tract infection; focal neurologic deficit with progressive or disabling symptoms; acute onset of urinary retention or overflow incontinence; loss of anal sphincter tone or fecal incontinence; saddle anesthesia; global or progressive motor weakness in the lower limbs; or duration of lower back pain >6 weeks.[3][4]

The rates of recurrence are significant, with 50% to 59% experiencing some degree of recurrent lower back pain, and 20% to 35% experiencing functionally disabling lower back pain between 6 and 22 months after acute lower back pain.[173]

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