Acute Lower Back Problems in Adults - Clinical Care

Clinical Care Methods

In the absence of the red flags described above, most patients with activity intolerance due to an acute episode of low back symptoms can be treated similarly during the first month. The goals are to provide patients with accurate information about low back problems, assist with symptom relief, and make appropriate activity recommendations.

Once the history and physical examination are complete, the patient can be assured that there is no hint of a dangerous medical condition causing the back problem and that a rapid recovery is expected. Symptom control methods focus initially on providing the patient with a comfort level adequate to keep the patient as active as possible while awaiting spontaneous recovery. Later in treatment, symptom control is considered an adjunct in helping the patient overcome a specific activity intolerance. The primary methods of symptom control are oral pharmaceuticals and physical methods.

Among the oral medications available to control the discomfort of acute low back problems, the panel recommends acetaminophen as reasonably safe and acceptable. Nonsteroidal anti–inflammatory drugs (NSAIDs), including aspirin, are also acceptable despite the potential for side effects, most frequently gastrointestinal irritation. Muscle relaxants, including benzodiazepines, have been found no more effective than NSAIDs in treating patients with acute low back problems, and potential side effects of these drugs include drowsiness in up to 30 percent of patients. The panel recommended that opioids be avoided if possible because of significant risks of debilitation, drowsiness, decreased reaction time, clouded judgment, and potential misuse. If chosen, they should be used only for a short time. The panel also recommended against the use of oral steroids, colchicine, or antidepressant medications for acute low back problems.

The panel found manipulation to be a recommendable method of symptom control. Manipulation seems helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. If no symptomatic and functional improvement has been noted after 1 month of manipulative therapy, this treatment should be stopped and the patient reevaluated. The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (TENS), and biofeedback techniques. Self–application of heat or cold may be taught to patients who choose such options to provide temporary relief of symptoms. Evidence does not support the use of trigger point, ligamentous and facet joint injections, needle acupuncture, or dry needling as treatment for acute low back problems.

The panel found that prolonged bed rest (for more than 4 days) may lead to debilitation and is not appropriate in the treatment of acute low back problems. A gradual return to normal activities is advisable, although bed rest for 2 to 4 days may be an option for patients with severe initial symptoms of sciatica. The patient whose symptoms are aggravated by lifting or prolonged sitting may require specific advice and exploration of alternatives. For most patients, aerobic activities that minimally stress the back (such as walking, biking, or swimming) can be started during the first 2 weeks of acute low back problems. After this, conditioning exercises for trunk muscles (in particular back extensors) may be helpful, especially if the patient's acute low back problems persist, although such exercises may initially aggravate symptoms.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.