Treatment of acute low back pain

INTRODUCTION — It is estimated that up to 84 percent of adults have low back pain at some time in their lives [1,2]. The vast majority of patients seen in primary care (>85 percent) will have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified [3-5]. For most of these individuals, episodes of back pain are self-limited. Patients who continue to have back pain beyond the acute period (four weeks) have subacute back pain (lasting between 4 and 12 weeks), and some may go on to develop chronic back pain (lasting >12 weeks) [6].

This discussion focuses on the initial treatment of nonspecific acute low back pain. The treatment of acute low back pain due to specific conditions is discussed in the appropriate topics. As examples:

●Treatment for vertebral compression fracture (see "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment")

●Treatment for lumbosacral radiculopathy (see "Acute lumbosacral radiculopathy: Treatment and prognosis")

●Treatment for lumbar spinal stenosis (see "Lumbar spinal stenosis: Treatment and prognosis")

The evaluation of low back pain, occupational back pain, and management of patients with occupational, subacute (4 to 12 weeks), and chronic (>12 weeks) back pain are also discussed separately.

●(See "Evaluation of low back pain in adults".)

●(See "Occupational low back pain: Evaluation and management".)

●(See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)

●(See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

●(See "Subacute and chronic low back pain: Surgical treatment".)

GENERAL APPROACH TO CARE — The goal of care for patients with acute low back pain is short-term symptomatic relief, since most will improve within four weeks. (See 'Prognosis' below and "Evaluation of low back pain in adults", section on 'Risk assessment subacute back pain'.)

We typically advise nonpharmacologic treatment with superficial heat. Massage, acupuncture, and spinal manipulation are other reasonable options depending upon patient preference and their cost and accessibility. There are no data demonstrating superiority of one modality over another [7]. For patients who prefer pharmacotherapy or in whom nonpharmacologic approaches are inadequate, we suggest a nonsteroidal anti-inflammatory drug (NSAID) with or without a skeletal muscle relaxant rather than acetaminophen for pharmacologic therapy. (See 'Nonpharmacologic therapies' below and 'Pharmacotherapy' below.)

This approach is consistent with the 2017 updated guideline of the treatment of acute, subacute, and chronic low back pain from the American College of Physicians and the 2022 Centers for Disease Control and Prevention (CDC) guidelines prescribing opioids for pain [4,8].

We do not advise bed rest for patients with acute low back pain. Patients who are treated with bed rest have more pain and slower recovery than ambulatory patients [9]. Activity modification should generally be minimal, with patients returning to activities of daily living and work as soon as possible. If activity is painful or increases pain, we advise patients to do as much as they can and gradually increase activity as tolerated. We emphasize the importance of avoiding prolonged periods of inactivity. However, we do not routinely refer patients with acute low back pain for exercise or physical therapy, and instead reserve those services for patients not improving with initial treatment or with risk factors for developing chronic low back pain (eg, poor functional or health status, psychiatric comorbidities). (See 'Exercise and physical therapy' below.)

Return-to-work recommendations should be individualized. For example, an office worker who has control over the pace of work, positioning while working, and/or work hours may be able to return to work promptly. However, those with physically demanding jobs may not be able to return to work immediately if light-duty options are not available.

Return-to-work advice for patients with occupational low back pain is discussed elsewhere. (See "Occupational low back pain: Evaluation and management", section on 'Return-to-work assessment'.)

NONPHARMACOLOGIC THERAPIES — Evidence of the effectiveness of nonpharmacologic therapies is generally of low to moderate quality [7]. The choice among these options depends upon patient preference and their cost and accessibility.

Heat — Heat is often applied with the rationale that it may reduce muscle spasm. A 2006 systematic review including six studies of low back pain found moderate evidence that a heat wrap may reduce pain and disability for patients with pain of less than three months' duration, although the benefit was small and short lived [10].

Massage — There is no evidence that massage offers clinical benefits for acute low back pain [11]. However, a randomized trial found that compared with usual care, when massage was chosen by the patient, it was associated with increased patient satisfaction [12].

Acupuncture — Acupuncture may be a reasonable option for interested patients with access to an acupuncturist. The evidence of benefit in acute low back pain is limited. Randomized trials of acupuncture tend to be small and heterogeneous in methodology, and blinding is difficult. Systematic reviews of acupuncture for acute low back pain have found inconsistent results [13]. Acupuncture is safe with few side effects. (See "Overview of the clinical uses of acupuncture", section on 'Adverse events'.)

There is more evidence to support the use of acupuncture in chronic low back pain. (See "Overview of the clinical uses of acupuncture", section on 'Low back pain'.)

Spinal manipulation — Spinal manipulation is a form of manual therapy that involves the movement of a joint near the end of the clinical range of motion.

Based upon the available evidence, spinal manipulation appears to confer modest improvements in pain and function. A 2017 systematic review and meta-analysis of spinal manipulative therapy for acute low back pain examined 26 randomized controlled trials [14]. Fifteen trials (1711 patients) provided moderate-quality evidence of improvement in visual analog pain scale, and 12 trials (1381 patients) showed moderate-quality evidence of improvement in function. Comparator groups were heterogeneous and included analgesics, exercise, and physical therapy. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported in 50 to 67 percent of patients. Serious adverse events (eg, worsening lumbar disc herniation, cauda equina syndrome) following spinal manipulation are rare.

Integrating spinal manipulation into the therapeutic plan for individual patients should depend upon their preferences and access to this type of intervention. There is little evidence to guide the duration of therapy. Most clinical trials have evaluated courses of twice-weekly manipulation for two to three weeks. There are no data on selecting practitioner type (eg, chiropractor, osteopath, massage therapist, physical therapist). (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Risks of spinal manipulation'.)

Exercise and physical therapy — Exercise therapy includes both self-care exercises done by the patient and supervised exercises in the context of physical therapy. In general, we do not refer patients with acute low back pain for exercise or physical therapy. However, we selectively refer patients with risk factors for developing chronic low back pain (eg, poor functional or health status, psychiatric comorbidities) who may benefit from immediate education by a physical therapist on how to avoid recurrences, appropriate levels of activity, and exercises to begin after the acute phase [15]. (See 'Prognosis' below and "Exercise-based therapy for low back pain".)

Although some studies do show modest efficacy of exercise therapy in selected cases of acute low back pain (<4 weeks) [16,17], systematic reviews have not clearly demonstrated a treatment benefit of generalized exercise therapy compared with other conservative treatments [18-21]. As an example, in one systematic review of 11 randomized trials of exercise in patients with acute low back pain, exercise therapy was not more effective than no treatment or other conservative treatments [19], which included nonsteroidal anti-inflammatory drugs (NSAIDs)/other analgesics, patient education programs, and/or advice to stay active. A subsequent randomized trial in patients with back pain for 16 days or less compared four sessions of physical therapy with usual care over four weeks; the intervention led to a small improvement in a disability index score at four weeks that was not considered to be clinically significant, and no difference at one year [22].

Early referral to a physical therapist may benefit patients with acute back pain who are at higher risk of developing chronic back pain, but this is unproven and may relate to education provided rather than exercise and therapy performed. While studies that have assessed such an approach showed improved outcomes for disability and lost work time, the majority of patients in these studies (>80 percent) had subacute or chronic rather than acute low back pain [15,23,24].

There is evidence to support exercise therapy for patients with subacute and chronic low back pain [16-18,25]. (See 'Prognosis' below and "Exercise-based therapy for low back pain", section on 'Prescribe exercise'.)

Other — Many other interventions have been suggested for acute low back pain with little or no evidence to support their use [11,12].

●Cold – Application of cold is often recommended for patients with acute back pain, with the rationale that it may help reduce edema. However, cold applied superficially does not penetrate far below the skin. A 2006 systematic review found only three studies evaluating cold for low back pain and was unable to find evidence of benefit [10].

●Muscle energy technique – The muscle energy technique is a treatment that involves alternating periods of resisted muscle contractions and assisted stretching. A 2015 systematic review of randomized trials found no evidence of effectiveness in patients with acute low back pain [20].

●Traction – There is no evidence that traction is beneficial for acute low back pain. A 2013 systematic review including 32 randomized trials of traction for low back pain (with or without sciatica) concluded that traction provides no benefits [26].

●Lumbar supports – There is no evidence to suggest that lumbar supports such as corsets or braces have therapeutic value for most patients with acute low back pain [27].

●Mattress recommendations – The role of type of mattress/firmness of sleep surface has not been studied in acute low back pain.

●Yoga – Studies on yoga and back pain have primarily focused on chronic low back pain. There is no evidence to support the use of yoga in acute low back pain. (See "Exercise-based therapy for low back pain", section on 'Choice of exercise: All programs are beneficial'.)

●Paraspinal injections – A variety of injections (eg, epidural spinal, trigger point, or facet join injections) have been advocated for patients with back pain. There is little evidence to support any type of injection for nonspecific acute low back pain. Injections for lumbosacral radiculopathy, spinal stenosis, and subacute and chronic low back pain are discussed elsewhere. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment", section on 'Glucocorticoid and other injections' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Epidural injections' and "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Options of limited utility'.)

PHARMACOTHERAPY

Initial therapy — If pharmacotherapy is used, we suggest a trial of short-term (two to four weeks) systemic treatment with a nonsteroidal anti-inflammatory drug (NSAID).

Nonsteroidal anti-inflammatory drugs — We start with systemic NSAID therapy in patients with acute low back pain without contraindications to this therapy. Many NSAID options exist (table 1). We generally start with either ibuprofen (400 to 600 mg four times daily) or naproxen (250 to 500 mg twice daily). Doses should be decreased as tolerated.

NSAIDs provide modest symptomatic relief for acute low back pain [28-30]. In a 2023 Cochrane meta-analysis of participants with acute or subacute low back pain, NSAIDS modestly reduced pain intensity (mean difference [MD] -7.29 on a 100 point scale, 95% CI -10.98 to -3.61) and disability (MD -2.02 on a 24 point scale, 95% CI -2.89 to -1.15) compared with placebo [31]. A 2008 systematic review and meta-analysis of 11 randomized trials reported similar findings [29]. NSAIDs were associated with more side effects compared with either placebo or acetaminophen.

NSAIDs may have significant renal, gastrointestinal, and cardiovascular adverse effects and may be contraindicated in some patients. All NSAID toxicities are more common in older patients. The adverse effects of nonselective NSAIDs and cyclooxygenase (COX)-2 inhibitors are discussed elsewhere. (See "Nonselective NSAIDs: Overview of adverse effects" and "NSAIDs: Adverse cardiovascular effects" and "Overview of COX-2 selective NSAIDs", section on 'Toxicities and possible toxicities'.)

Limited benefit of acetaminophen — Acetaminophen has historically been considered an option for first-line therapy for low back pain. However, evidence of efficacy has been mixed [29,32,33], and 2016 and 2023 Cochrane reviews concluded that there was high-quality evidence that acetaminophen showed no benefit compared with placebo in acute low back pain [31,34]. There is also evidence that the addition of acetaminophen to short-term NSAID therapy provides no further benefit [35]. Given that acetaminophen has clear risks and questionable benefit, we do not recommend it as either initial or supplemental therapy for the majority of patients with acute low back pain.

However, in selected patients for whom there are no safe alternatives and acetaminophen is the least potentially harmful treatment, we believe it reasonable to consider a trial of acetaminophen as initial therapy. We use acetaminophen 650 mg orally every six hours as needed (maximum 3 grams per 24 hours) for most adults, although we would use a lower total daily dose for older adult patients, those with any hepatic impairment, and patients with other factors that predispose to hepatotoxicity (table 1). (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation", section on 'Clinical factors that may influence toxicity'.)

Hepatotoxicity is the primary concern with acetaminophen use; the risk of liver injury is dose related, but the dose causing toxicity may vary from patient to patient. Many prescription analgesics and over-the-counter products contain acetaminophen, and the total dose of acetaminophen should be considered when patients are taking multiple medications.

Other less common but possible adverse effects that have been associated with acetaminophen use include chronic kidney disease, hypertension, and peptic ulcer disease. (See "Epidemiology and pathogenesis of analgesic-related chronic kidney disease", section on 'Acetaminophen' and "NSAIDs and acetaminophen: Effects on blood pressure and hypertension", section on 'Effects of acetaminophen on blood pressure' and "Unusual causes of peptic ulcer disease", section on 'Non-NSAID medications'.)

Second-line therapy — For patients with pain refractory to initial pharmacotherapy, we suggest the addition of a nonbenzodiazepine muscle relaxant. In patients who cannot tolerate or have contraindications to muscle relaxants, combining systemic NSAIDs and acetaminophen is another option, though there are few data to support the use of this combination.

Combination with muscle relaxants — Muscle relaxants are a diverse group of drugs with similar physiologic effects including analgesia and a degree of skeletal muscle relaxation or relief of muscle spasm. They include benzodiazepines, cyclobenzaprine, methocarbamol, carisoprodol, baclofen, chlorzoxazone, metaxalone, orphenadrine, and tizanidine.

Patients who can tolerate the potential sedating effects of these medications may benefit from the addition of a nonbenzodiazepine muscle relaxant to initial pharmacotherapy with NSAIDs or acetaminophen. We generally do not start these medications as initial therapy, as they tend to have sedating side effects that limit patients' ability to work or drive. Risks of these agents increase with age, and these agents should be used with caution in older adults.

Cyclobenzaprine is a reasonable first-choice drug. For patients who cannot tolerate the sedating effects of muscle relaxants during the daytime, NSAIDs or acetaminophen during the day with muscle relaxants before bedtime may be helpful. Benzodiazepines should not be used because they are not effective in improving pain or functional outcome [36], and there is potential for abuse.

●Efficacy – Muscle relaxants provide short-term, symptomatic relief for patients with acute low back pain. A 2023 Cochrane review found that nonbenzodiazepine muscle relaxants are more effective than placebo for short-term relief of acute low back pain (risk ratio [RR] 0.58, 95% CI 0.45-0.76) and for improved function (RR 0.55, 95% CI 0.40-0.77) [31]. A 2021 meta-analysis including 17 randomized trials had similar findings [37]. There is some evidence that cyclobenzaprine, methocarbamol, carisoprodol, and tizanidine are more effective than other muscle relaxants [38,39].

Evidence on combination therapy with NSAIDs is mixed. A randomized trial in 197 patients with acute low back pain comparing treatment for one week with aceclofenac 100 mg twice daily with or without the addition of tizanidine 2 mg twice daily found improved pain relief and decreased functional impairment with combination therapy [40]. However, in other randomized trials, there was no benefit from the addition of a skeletal muscle relaxant to NSAID treatment [41-43].

There are no studies evaluating the combination of acetaminophen with muscle relaxants.

●Adverse effects – Meta-analyses have reported an increased risk of adverse effects from muscle relaxants compared with placebo (RR 1.5, 95% CI 1.14-1.98) [31,37]. The primary adverse effects (sedation, dizziness) of muscle relaxants relate to their central nervous system and anticholinergic activity; these are more likely to be problematic in older patients. Dependence and abuse potential are concerns with benzodiazepines. Carisoprodol also has abuse potential, particularly in patients with a history of substance abuse [44]. (See "Drug prescribing for older adults".)

Refractory or severe pain — Evidence does not support the use of opioids and tramadol in acute low back pain. However, for patients who do not have adequate relief from or have contraindications to other agents and nonpharmacologic therapies, a short course of these agents may be appropriate.

Opioids — Opioids have few benefits when added to NSAID therapy. If opioids are used for acute low back pain, we agree with 2022 US Centers for Disease Control and Prevention (CDC) guideline recommendations for opioid prescribing. Clinicians should prescribe the lowest effective dose of short-acting opioids in a quantity no greater than needed for the expected duration of pain severe enough to require opioids, after reviewing controlled substance prescriptions using state prescription drug monitoring program (PDMP) data [8]. We also think opioid therapy should generally be limited to a duration for acute pain to less than three days for most patients unless circumstances clearly warrant additional therapy. Even in those cases, more than seven days is rarely needed [45].

The limited data on the efficacy and safety of opioids for acute low back pain suggest they are not effective compared with placebo and/or NSAID therapy [46]. In a randomized trial of 347 patients presenting to the emergency department or primary care clinic for acute low back or neck pain, oxycodone up to 20 mg daily for six weeks was no more effective for pain relief or functional improvement than placebo, each in addition to standard care (mean difference 0.53 on a 10-point scale, 95% CI 0-1.07) [47]. A separate randomized trial of patients with acute, nontraumatic, nonradicular low back pain also found no difference in pain or disability after seven days of naproxen plus oxycodone/acetaminophen compared with naproxen alone [42].

The appropriate opioid dosing regimen is unknown. One trial comparing scheduled dosing of opioids with as-needed dosing found better outcomes in the scheduled dosing group [48]. One strategy is to limit opioids to bedtime use to facilitate sleep and reduce the chances of developing dependence or tolerance.

Adverse effects of opioids include sedation, confusion, nausea, and constipation. Respiratory depression is an issue at higher doses but rarely at the doses used for acute low back pain. As with all medications, older patients are more susceptible to side effects. Patients given combination drugs containing acetaminophen or NSAIDs should be advised not to use them concurrently with over-the-counter analgesics without carefully reviewing the contents with a health care professional.

Misuse is a concern with opioids [49]. While it has been reported that addiction and abuse are rare with short-term opioid prescriptions for acute pain, one trial noted that at one-year follow-up, the risk of potential opioid misuse was higher in patients randomized to six weeks of oxycodone for treatment of acute low back or neck pain when compared with the placebo group (20 versus 10 percent) [47].

Tramadol — Tramadol is an opioid agonist that also blocks reuptake of serotonin and norepinephrine [50]. We prescribe tramadol similarly to opioids, limiting regular use to a few days and total use to two weeks. Tramadol may have a lower risk of constipation and dependence than conventional opioids but carries the risk of serotonin syndrome, especially when combined with other serotonergic agents [50,51]. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Mixed-mechanism drugs: Tramadol and tapentadol' and "Use of opioids in the management of chronic non-cancer pain", section on 'Opioids'.)

While randomized trials have shown that tramadol may be effective for chronic back pain, there are few data evaluating tramadol for acute low back pain [52-54].

Other medications — Drugs with limited or no evidence of effectiveness include:

●Antidepressants – There is no evidence to support the use of antidepressants in treatment of acute low back pain. However, in patients with concurrent depression, we ensure that the depression is appropriately treated. (See "Unipolar major depression in adults: Choosing initial treatment".)

These medications may be considered in the management of subacute or chronic back pain. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Pharmacologic therapies'.)

●Systemic glucocorticoids – There is no evidence to support the use of systemic glucocorticoids in acute nonspecific back pain [7,55]. Small randomized trials in patients with nontraumatic back pain presenting to the emergency department comparing systemic steroids with placebo have found no benefits [56,57]. A systematic review found that systemic glucocorticoids are unlikely to provide meaningful benefit in patients with nonradicular back pain [58].

The use of systemic glucocorticoids for the treatment of acute lumbosacral radiculopathy is discussed elsewhere. (See "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Systemic glucocorticoids'.)

●Antiepileptics – There is no evidence to support the use of antiepileptics in treatment of acute low back pain. These medications may be considered in the management of subacute or chronic back pain. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Pharmacologic therapies'.)

●Topical agents – There is low-quality evidence that topical capsicum may provide immediate relief for patients with acute back pain [59]. There is no evidence to support the use of lidocaine patches in this setting.

●Herbal therapies – Though these treatments may be commonly used by patients, the evidence to support the use of herbal therapies for low back pain is limited. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Pharmacologic therapies'.)

PATIENT EDUCATION — Patient education is an important aspect of care. A 2015 systematic review of studies evaluating patient education for acute and subacute low back pain (eg, education on the benign nature and good prognosis of acute low back pain, advice to stay active) found moderate-quality evidence that, compared with usual care, patient education reduces acute low back pain-related primary care visits [60]. Our view is that patient education is necessary, but not sufficient, to result in improved outcomes.

Education should include information about the causes of back pain, favorable prognosis, generally minimal value of diagnostic testing, activity and work recommendations, and when to contact a clinician for follow-up [61]. (See 'Information for patients' below.)

PROGNOSIS — The prognosis for acute low back pain is excellent; only one-third of patients seek medical care at all [62]. Of those who present for care, 70 to 90 percent improve within seven weeks [63,64].

Recurrences are common, affecting up to 50 percent of patients within six months and 70 percent within 12 months [65,66]. Similar to the initial episode, recurrences have a favorable prognosis.

Some patients with acute low back pain will go on to develop chronic low back pain. Estimates of the percentage of patients who develop chronic back pain vary. In one prospective cohort study of patients with acute back pain seen in primary care, chronic back pain was diagnosed in 20 percent of patients within two years of their initial visit [65]. However, other studies have suggested only 5 to 10 percent of patients with acute low back pain go on to develop chronic low back pain [66-68].

Predictors of disabling chronic low back pain at one year include maladaptive pain coping behaviors, functional impairment, poor general health status, presence of psychiatric comorbidities, or nonorganic signs [69,70]. Maladaptive coping behaviors include fear avoidance (avoiding usual or recommended activities because of fear that they will cause worsening pain or hinder recovery) and catastrophizing (negative beliefs about pain or illness leading to patients imagining the worst possible outcome). (See "Evaluation of low back pain in adults", section on 'Physical examination'.)

Stratifying care in patients with acute low back pain based upon risk assessment for chronicity is not of proven benefit. While studies that have assessed such an approach showed improved outcomes for disability and lost work time, the majority of patients in these studies (>80 percent) had subacute or chronic rather than acute low back pain [15,23,24]. Further, a United States study showed no advantage of this approach, in contrast to similar studies in the United Kingdom [71].

PREVENTION — Exercise interventions may have some value in preventing recurrences of low back pain. (See "Exercise-based therapy for low back pain", section on 'Subacute and chronic low back pain: Exercise is beneficial'.)

There are few data to support other interventions, such as lumbar supports, smoking cessation, or weight loss, for the prevention of low back pain [27,72]. However, interventions such as smoking cessation or weight loss may be otherwise beneficial for health. There also is no evidence that spinal manipulation reduces the risk of recurrence of back pain [73]. Ergonomic interventions for the prevention of occupational low back pain are discussed elsewhere.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Low back pain in adults (The Basics)" and "Patient education: Spinal stenosis (The Basics)" and "Patient education: Herniated disc (The Basics)")

●Beyond the Basics topic (see "Patient education: Low back pain in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●The majority of patients improve; nonpharmacologic therapy preferred – Most patients with acute low back pain improve regardless of specific management. We typically suggest nonpharmacologic therapy with superficial heat (Grade 2C). Massage, acupuncture, and spinal manipulation are other reasonable options depending upon patient preference and their cost and accessibility. There are no data demonstrating the superiority of one modality over another. Bed rest is not advised, and activity modification should be kept to a minimum. (See 'General approach to care' above and 'Nonpharmacologic therapies' above.)

●Most patients are not referred for physical therapy – We do not refer most patients with acute low back pain for exercise or physical therapy. However, we selectively refer patients with risk factors for developing chronic low back pain (eg, poor functional or health status, psychiatric comorbidities) who may benefit from immediate physical education by a physical therapist, although this is unproven. (See 'Exercise and physical therapy' above.)

●Short-term NSAID therapy an option for some patients – For patients who prefer pharmacologic therapy or in whom nonpharmacologic approaches are inadequate, we suggest short-term (two to four weeks) treatment with a nonsteroidal anti-inflammatory drug (NSAID) as initial therapy (Grade 2C) (table 1). Acetaminophen is an acceptable alternative option in patients with a contraindication to NSAIDs, although it has limited efficacy. (See 'Initial therapy' above.)

●Addition of a skeletal muscle relaxant for patients with refractory pain – For patients with pain refractory to initial pharmacotherapy, we suggest the addition of a nonbenzodiazepine muscle relaxant (Grade 2C). In patients who cannot tolerate or have a contraindication to muscle relaxants, combining NSAIDs and acetaminophen is another option. (See 'Second-line therapy' above.)

●Limited role for opioids – We recommend against the use of opioids as initial therapy for patients with acute low back pain if there are no contraindications to other treatments (Grade 1B). Evidence to support the use of opioids and tramadol in acute low back pain is limited and potential harms are well documented. If opioids are used, the duration of therapy should be limited to three to seven days. Tramadol should not be prescribed for more than two weeks. (See 'Refractory or severe pain' above.)

●Importance of patient education – Patient education is an important aspect of care. Education should include information about the causes of back pain, favorable prognosis, generally minimal value of diagnostic testing, activity and work recommendations, and when to contact a clinician. (See 'Patient education' above.)

●Reassess if persistent symptoms after four weeks of pharmacotherapy – Patients who do not improve after four weeks of pharmacotherapy should be reassessed. Some patients with acute low back pain will go on to develop chronic low back pain. Predictors of disabling chronic low back pain at one year include maladaptive pain coping behaviors, functional impairment, poor general health status, presence of psychiatric comorbidities, or nonorganic signs. (See 'Prognosis' above.)

●Prevention – Exercise interventions may have some value in preventing recurrences of low back pain. (See 'Prevention' above.)