The Lowdown on Acute Low Back Pain

NOVEMBER 01, 2006
Guido R. Zanni, PhD, and Jeannette Yeznack Wick, RPh, MBA, FASCP

Whether one calls it lumbago, back strain, hyperextension, facet joint disorder, or a degenerative disk problem, low back pain (LBP) is common. Lifetime prevalence for both genders approaches 85%.1,2 Recurrence approaches 20% within 1 year and 44% within 10 years,1,2 and approximately 15% to 20% of patients have related limitations for up to 1 year.3 Among young adults (<45 years), it is the most frequent cause of inactivity.1,4 Despite its impact, approximately 20% of those afflicted do not seek medical attention.

Contrary to updated information, certain myths persist:

  • One myth is that diagnosis is precise. In fact, 85% of diagnoses are nonspecific.
  • Another myth is that diagnostic imaging is necessary. Actually, experts recommend imaging only if pain persists for 6 weeks.
  • Some think that bed rest and back exercises hasten recovery. After 2 or 3 days, however, bed rest prolongs disability, and specific exercises help no more than other interventions.
  • The utility of corsets, back braces, or long-term lumbar traction is controversial, too.
  • Seeing a specialist will not necessarily speed recovery. Care from primary care providers is as good.1,4-8

Classification and Assessment

Back pain is classified as acute (lasting less than 6 weeks), subacute (6-12 weeks), and chronic (longer than 12 weeks).4 For most, LBP is acute, temporary, and minor. Less than 2% of LBP is linked to serious pathology, such as metastatic cancer, osteomyelitis, or abscess.5,9 If neurologic in origin, LBP most often is due to herniated disk.1 Pain associated with bladder or bowel incontinence may reflect herniation, and unilateral pain may point to kidney infections or stones.11 Table 19,10 lists red flags signaling serious problems.


Treatment focuses on symptom alleviation and prevention. LBP rarely becomes a chronic condition, and most cases resolve within 2 weeks.12,13

Mild analgesics and/or skeletal muscle relaxants (SMRs) generally are used first. Acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) normally provides adequate short-term relief.14-16 In specific cases, certain drugs may be preferred or contraindicated:

  • In sulfa-allergic patients, celecoxib (a sulfonamide) is contraindicated
  • If platelet aggregation must be avoided, salsalate, choline magnesium trisalicylate, and cyclooxygenase-2 selective agents are preferred
  • If swallowing is problematic or if fine titration is necessary, liquid formulations of some NSAIDS are available

Severe pain warrants short-term opioids from Schedules III and IV. All opioids have similar pharmacologic profiles, so clinicians should use side-effect profile as the selection criterion and increase the dose until pain relief occurs.

Combining an SMR and an NSAID may be superior to using an NSAID alone.17-19 Patients with histories of LBP may ask for a specific NSAID or SMR (Table 210,20). The SMRs differ only in adverse effect and abuse potential, and here too clinicians should work with patients to select drugs with acceptable potential or actual side effects.

Patient Counseling

Pain generally promotes adherence, but not always. Table 3 highlights adherence issues.

?Begin counseling with the basics. For 24 hours, patients can apply ice, but if it is applied directly to skin it can burn. Tell patients to limit the application of ice to 15 to 20 minutes 4 to 6 times daily if it is wrapped in a towel and comfortable. After that, suggest alternating ice and comfortable heat for 20 minutes every 3 to 4 hours.21

?If patients describe pain inadequately or have yet to see a prescribing clinician, suggest a symptom diary. Knowing the time, type, location, and duration of symptoms helps clinicians individualize treatment plans.14

?Patients should seek immediate health care if pain radiates along the lower leg; if foot, groin, or rectum numbness occurs; if nausea or vomiting, fever, weakness, sweating, or incontinence begins; or if intense pain prevents mobility. They also should call a physician if LBP continues after 2 to 3 weeks.22

?Active people recover most rapidly. Patients should avoid activities that worsen pain but continue mild and gradually more strenuous exercise.13,23

?Suggest sleeping flat on the back, propping the knee or leg comfortably with a pillow14

?Provide written materials, such as those available on MEDLINE plus ( backpain.html)

?Analgesia works best before pain intensifies.14 Remind patients to schedule analgesics and to take them "by the clock" to break the pain cycle. Labeling prescriptions with specific, convenient times works best.

?Discuss potential side effects. If the patient considers sedation to be a problem, call the prescriber and suggest a less-sedating drug. Discuss the effects of sedation on driving. Some states prohibit driving while taking sedating agents.24

?Many patients take multiple medications. Scheduling analgesics and SMRs at similar times, not at odd or inconvenient hours, can improve adherence. Avoid directions such as "Take X tablets as needed." Patients vary greatly in their perception of "as needed."25

Often, pharmacists associate "LBP" with "abuser." Unless other red flags are present (lost prescriptions, frequent refills, manipulative behavior), LBP patients deserve adequate treatment.

Final Thought

Good counseling begins with dispelling myths and watching for signals of serious pathology while assuring patients that it is rare. Direct and simple instructions are often best.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria,Va. Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. The views expressed in this article are those of the authors and not those of any government agency.

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