The management of acute low back pain in adults: a guide for the primary care physician, Part II

Abstract

When a patient presents with acute low back pain (LBP), any red flag warnings of serious disease should first be excluded. Yellow and blue flag warnings of psychological factors should be noted. A psychological opinion of patients with substantial psychological distress could be sought. Advice may be offered on the benign nature of non-specific LBP. The person should be encouraged to be physically active and to continue with normal activities as far as possible. A structured exercise programme, that includes aerobic activity, movement instruction, muscle strengthening, postural control and stretching, should be devised. A combined exercise and psychological treatment programme that includes a cognitive behavioural approach can be considered in patients with significant disability or substantial psychological distress. A course of acupuncture may also be added. Manual therapy, including spinal manipulation, could be considered. Paracetamol should be the first medication option. If this is inadequate, a nonsteroidal anti-inflammatory drug or weak opioid, or both, can be added. Individual risks for side-effects and the patient’s preference should be taken into account. Strong opioids should be considered in patients in severe pain, but for short-term use only. Antidepressants and gabapentine or pregabolin can be considered when there is a neurogenic component of the pain. Consider obtaining a surgical opinion on patients who have completed an optimal package of care and who still have persistent severe non-specific LBP. Progressive neurological fallout requires a surgical opinion.