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New US guidelines say movement, not bed rest, should be the first response to back pain
By Arvin Shirali, . Life and Health Today.
Doctors seeing a new bout of low back pain should start with movement, heat and ordinary painkillers off the pharmacy shelf, according to a clinical guideline the American Academy of Pain Medicine has published in the journal Pain Medicine. It covers acute pain, which the document defines as lasting six weeks or less, in an episode running more than 24 hours with at least a month free of pain on either side of it.
The FDA paid for the work. The panel declared no conflicts of interest.
"We tried to prioritize the self-management aspect of caring for acute low back pain to try to empower patients to understand that there is a lot they can do to get the ball rolling on recovery," said Devan Kansagara, MD, professor of medicine at Oregon Health and Science University in Portland, Oregon, and co-chair of the guideline panel, as quoted by Medscape Medical News.
The first recommended step is education: clinicians should tell patients that low-impact movement is safe and that usual exercise can continue, adjusted for pain. Applying heat to the affected area is listed as useful, as are over-the-counter nonsteroidal anti-inflammatory drugs, a class of medications that includes common pain relievers such as ibuprofen and naproxen. Bed rest, by contrast, is out. "We've learned that bed rest is probably going to prolong the recovery and make things worse," Kansagara told Medscape.
If two weeks of self-management does not bring improvement, the guidance says clinicians may move to prescription-strength nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, physical therapy, or acupuncture. A short course of systemic steroids or a referral for epidural steroid injections, which deliver anti-inflammatory medication directly around the spinal nerves, may also be considered at that stage. The muscle relaxant carisoprodol is specifically not recommended because of safety concerns.
On opioids, the guidance is direct: routine prescribing is not recommended for acute low back pain. The panel says such drugs should be reserved for cases where a clinician judges that the potential benefit outweighs the known risks, which include addiction and overdose. "We want clinicians to still retain the decision-making capacity to judge when it might be appropriate," Kansagara said. "But it's certainly not a good routine initial treatment for low back pain."
Scans are discouraged as well. For a straightforward episode under six weeks there is no need for an X-ray or an MRI, the panel says, unless something in the patient's symptoms or risk profile points to a serious problem in the spine itself.
Managing low back pain costs the United States an estimated $40 billion a year, the report said, or roughly $2,000 for each patient, and in most cases nobody ever finds an underlying cause.
A doctor outside the panel put a practical question to it. Puneet Aggarwal, MD, asked whether patients looking for relief will accept a narrower set of treatments. The report describes him as a specialist in pain and sports medicine, and a site medical director for Advocate Health in Charlotte, North Carolina. He told Medscape that what they usually want is a diagnosis, a sense of how long it will last and advice on stopping it coming back, and that listening properly to those concerns tends to produce better outcomes whatever is prescribed.
What the guidance does not settle is whether patients who follow it will recover faster than those who receive more intensive early treatment. The document sets out a recommended sequence, but the underlying question of how individual patients respond to each step remains one for the clinician who knows their history. Anyone weighing these options alongside an existing condition or medication should work through that with their own doctor.
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