Oregon Health & Science University
  • Jason J. Chang, M.D.
    Dr. Chang is a neurologic surgeon with subspecialty training treating complex spine problems.

Conservative care best for most acute low back pain

Low back pain is very common, but it’s a complex challenge to diagnose and treat. Patients often can’t accurately pinpoint the source of discomfort other than generalized low back, and they report subjective degrees of pain. As providers, we have lacked consensus on treatment recommendations for low back pain.

In October last year, an OHSU multidisciplinary committee of thought leaders (led by Roger Chou, M.D., who co-authored a set of opioid-prescribing guidelines issued by the Centers for Disease Control and Prevention in 2016) established new guidelines for when and how to image and intervene in low back pain cases in order to standardize our approach and add quantitative measurements. For the majority of patients, the guidelines call for no imaging, diagnostic tests or intervention and instead recommend shared decision-making for conservative therapy.

How serious is it? The 5-minute assessment

Most people with low back pain will be low risk, responding to time, self-care and conservative therapies. A small percentage may benefit from advanced therapy and a few will have red flags for immediate imaging, including high risk of cancer, sudden motor deficits, new incontinence and symptoms associated with spinal infection. Though patients with high-risk symptoms are clearly identifiable, that leaves a large gray area that can be harder to judge.

At OHSU, the consensus is to use the Keele STarT Back Screening Tool or SBST in the absence of red flag symptoms. This short questionnaire helps clinicians identify modifiable risk factors and stratify patients with new episodes of back pain into risk categories. Based on the guidelines, the different risk categories suggest next steps.

Low risk patients
Massage therapy
Physical therapy
Spinal manipulation
Medium to high risk patients
Cognitive behavioral therapy
Exercise therapy
Intensive interdisciplinary rehabilitation
Massage therapy
Progressive relaxation
Physical therapy
Spinal manipulation

Measurable, clinically significant progress toward the therapy plan of care goals and objectives should be documented using evidence-based objective tools, such as the Oswestry Disability Index.

Surgery and pain relief aren’t synonymous

In treating low back pain, we’ve learned that surgical intervention may help people get back to work or off medications more quickly, but it doesn’t necessarily change the long-term outcome or perception of pain. Surgery can’t fix the natural progression of degenerative disease. However, surgery is clearly beneficial in cases where nerves are pinched, causing sciatica or focal weakness in the foot. The challenge is identifying and understanding what is acceptable or realistic. Medication also has a limited role to play in low back pain. As a first-line therapy, the guidelines recommend nonsteroidal anti-inflammatory drugs, acetaminophen and muscle relaxants. Most other options, including opioids and steroid injections, have limited use or are not supported by best available evidence or consensus.

Steps to take for the “gray” area

For patients who seek help but fall in the low to medium risk categories, consider the following protocol to assess whether the patient needs a referral to a spine specialist:

  • Educate on low back pain, advise on self-care and maintaining mobility
  • Begin a longitudinal assessment for worsening symptoms through objective/quantifiable measures.
  • Initiate first-line therapies.
  • If conservative therapies fail, determine the correlative anatomic distribution of pain and symptoms.
  • Consider advanced assessments through specialty-focused providers.

Contact us

OHSU is available to answer questions about our new guidelines for low back pain or any spine issues. Please call the OHSU Physician Advice and Referral Service at 503‑494‑4567 for physician advice. To refer a patient, please fax to 503‑346‑6854.

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