Author: Charlotte Davies / Codes: MuC1, MuC5, MuP1, SLO1 / Published: 04/10/2017


The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

Acute back pain is something that we see fairly often in the emergency department and while we’re all good at ruling out red flags and diagnosing “sciatica” or “musculoskeletal pain”, we may not put the same amount of effort in advising our low risk patients on ways to improve.


This is what I usually tell those patients who don’t have any red flag symptoms that I am happy to discharge. They are tips that I’ve collected from both personal and professional experience.

1. Don’t go to work until you can walk but continue activities of daily living

Everything you read says you need to go back to work as soon as possible, and I know there is lots of evidence saying that long term absence from work is not helpful. For the first few days most people will find the pain is too distracting to be effective at work. Public transport jolts every muscle in the body. Driving is not recommended – how would you do an emergency stop?

When you do return to work, ensure everyone knows you have a problem so that you are not expected to lift patients, move trollies, or do CPR. Even as a doctor, we do lots of manual handling.

Whilst you are off work, make sure you continue your daily activities as normally as possible. Bed rest will only make things worse.

2. Analgesia

Regular analgesia is essential. Paracetamol has recently been suggested as ineffective for back pain, but I think most of us would still use it, especially in combination with other therapies. The studies mentioned in that hyperlink have not been powered to look for reduction in pain levels, but to see if paracetamol shortens duration of symptoms. We give paracetamol not to shorten duration, but to allow activities of daily living to continue, and the patient to be comfortable whilst it heals.

Codeine helps reduce the pain but has lots of side effects (like constipation). Anti-inflammatories are essential, and ibuprofen can be just as effective as the others, with less side effects. The BNF lists the maximum dose of ibuprofen as 2.4g/ day – which is 600mg QDS. There is still a risk of gastro-intestinal upset, and patients should be counselled about this.

I normally say to patients:

“I am going to give you enough pain relief so that you can start walking and performing your normal daily activities. Once you can do this, it will take time for your body to heal itself, and return to normal. This will take time, and during this time, a little bit of discomfort can be expected as your body’s way of warning you not to push things too far”.

Hot and cold help as pain killers. A cold can of beer can be useful, as it fits underneath a buttock nicely. Imbibing the beer is unlikely to help, particularly in combination with NSAIDs!

3. Exercise

Early mobilisation and physiotherapy is essential. Check to see what your departmental policy is – many ED physios do not see back pain, and it should go to the main physios, or back to the GP. For staff, occupational health are normally very supportive. The internet has lots of back injury exercises – the key is that if it hurts, stop. If it’s uncomfortable, that’s OK. Most departments have back pain leaflets as do NICE and the Arthritis Research Campaign with some good physio suggestions.

4. Standing

Sitting down when you have back pain is really painful as all of your weight goes through your back onto your bottom. Lying down is most comfortable, followed by standing. If you really must sit, try to perch against the chair, making sure you are tipping forward.

5. Adaptations

–        Getting dressed is difficult as bending down to put your socks on is impossible. Lean against a wall, and allow the wall to support you as you bend down to put your underwear and socks on. Or get someone else to put them on for you.

–        A towel rolled up, underneath your lumbar spine may help to provide support and be more comfortable.

–        When coughing or sneezing, engage your pelvic floor by switching on your “bikini muscles”. For men, when you tighten the right muscles, you should see the scrotum lift. This helps to brace the back, so that a cough does not jarr as much.

–        Get a chair wedge. These great devices are easy to get from the internet, and make sitting more comfortable. They are slightly wobbly, so encourage movement and tip you very slightly forward.

If you sit a lot at work, a standing desk or kneeling chair may also be useful – occupational health should be able to advise on these.

6. Imaging

Plain film imaging is not recommended. MRI is not useful unless surgery is an option and NICE guidelines which advise against MRI scans in several scenarios. Many studies have shown a high percentage of asymptomatic people have been found to have abnormalities on their MRI scan, as detailed below:

This is looked at in some detail on this excellent twitter thread from Thomas Jesson below.

There’s some excellent advice and summaries from future NHS here.

7. Prevention

Prevention of back pain is difficult, and controversial. This is really important for all hospital staff, as back injuries can be life changing. Poor handling is one of the most common causes, which is why manual handling is carefully legislated (by the health and safety at work act of 1974, the management of health and safety workplace regulations 1999 and the manual handling operations regulations 1992).

Like anything, the first step to moving carefully is to do a risk assessment. The mnemonic “LITE” is suggested – look at the load, the individual, the task and the environment. Thirty seconds spent clearing your environment of obstacles will be time well spent.

When lifting and moving, have a stable base with the weight central. Keep the natural curves of your back, and push up with your knees, not your back.

Remember to emphathise with the patient, and let them know you understand they are in pain, and it is affecting their life. Avoid nocebo whilst talking to them!

We hope you’ve found this article useful, and we look forward to hearing your suggestions for managing non traumatic, lower back pain.