Symptomatic Treatment of Acute Musculoskeletal Lower Back Pain

Analgesia

Patients in pain should be given analgesia. The Cochrane Collaboration found that non-steroidal anti-inflammatory drugs (NSAIDs) are slightly more effective for short term symptomatic relief in patients with acute back pain (without sciatica) when compared with placebo. However, they comment that many of the studies are of poor quality and there are few data on long term results and side effects.⁵

Muscle relaxants

Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution.^7,8

Patients should be advised to stay active. Although many people get some relief from low back pain by lying down, advice to rest in bed is less effective in reducing pain and improving an individuals ability to perform every day activities than advice to stay active.⁹

Physiotherapy. While it has been argued that physiotherapy is of little value in back pain,¹⁰ the trial to which the author refers¹¹ compared routine physiotherapy with an assessment session and advice from a physiotherapist. A physiotherapist assessing and advising a patient is likely to spend much more time doing so than a doctor in the ED so this trial cannot say that referral to a physiotherapist is of no value. Another study has shown that manipulation followed by exercise was of benefit.¹² There is great diversity of patients in many of the trials and equal diversity among physiotherapists and the treatments they offer and so it is difficult to conclude definitively on the value of physiotherapy for any individual patient.

Other treatments that have been investigated for low back pain are:

• Traction. Studies have shown that traction (continuous or intermittent) as a single treatment for LBP was no more effective than placebo.¹³
• Massage. While massage is of value for chronic back pain, there is still not enough evidence about massage for acute back pain.^14,15
• Antidepressants. Antidepressants are a common treatment for low-back pain. They are prescribed for three main reasons: to provide pain relief, help with sleep and reduce depression. However a Cochrane review could find no convincing evidence that antidepressants relieve back pain or depression more effectively than placebo. They did not result in any other apparent benefits in the treatment of back pain and they had side effects.¹⁶ They may have a role in neurological pain in sciatica.
• Local heat. There is moderate evidence that heat wrap therapy reduces pain and disability for patients with back pain that lasts for less than three months. The relief has only been shown to occur for a short time and the effect is relatively small. The addition of exercise to heat wrap therapy appears to provide additional benefit.¹⁷
• Local cold. There is still not enough evidence about the effect of the application of cold for low-back pain of any duration.¹⁷
• Individual patient education for low back pain. People with low-back pain who received an in-person patient education session lasting at least two hours in addition to their usual care had better outcomes than people who only received usual care. Shorter education sessions, or providing written information by itself without an in-person education session, did not seem to be effective.¹⁸
• Spinal manipulative therapy. Spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.¹⁹
• Exercise therapy. In acute low-back pain, exercise therapy has not been shown to improve pain or function over no treatment or other conservative treatments. However it appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear.^20,21
• Lumbar supports. It is unclear whether lumbar supports are more effective than no or other interventions for treating low-back pain.²²
• Acupuncture. There is no evidence to support the use of this.²³
• Strong opiates (e.g. oramorph). There are no published trials looking at this.²⁴

Note that the above evidence largely relates to acute back pain. The results for chronic and subacute back pain may be different.