Lower back pain is common, and many adults experience it at some point in their lives. Common causes of back pain include injuries to the soft tissues in the back (such as muscles or ligaments). These injuries can result from lifting heavy objects, stress, or an injury to a disc. More serious causes of back pain include vertebral fractures, tumours or infections; these injuries can result in nerve damage. These guidelines focus on the management of acute lower back pain.
Guidelines
- When lifting heavy objects, people should bend their knees and keep their back straight to prevent lower back pain. *
- Paracetamol may be effective at relieving some subsets of acute lower back pain. *
- Nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen) may be effective at relieving acute lower back pain but may cause side effects including gastric irritation, potential kidney interactions, and high blood pressure. *
- Heat wrap therapy may provide some short-term pain relief and reduce disability in those with a combination of acute and subacute low back pain. *
Good practice points
- The person should sit or lie down in a position most comfortable to them.
Chain of survival behaviours
Prevent and prepare
- Exercise regularly.
- If working at a desk, use an ergonomic chair.
- Educate yourself on how to reduce the risks of lower back pain.
- Modify the way you lift items by bending your knees and keeping the back straight.
- Wear a combination of accessories to protect the back, such as back belts or shoe insoles.
- Change your position regularly and avoid holding a certain position or movement for too long.
Early recognition
The person was involved in a high-speed, direct impact incident, or may have been using their back for physical activity such as lifting or stretching. They may experience:
- Sudden back pain.
- Back pain combined with neck pain or a tingling feeling running down the back of one leg.
- Sudden inability to walk due to lower back pain.
First aid steps
- 1. Comfort and reassure the person.
2. Determine the cause of the back pain. If it is the result of a fall or other traumatic incident, follow the first aid steps for Spinal injury.
3. Help the person move into a comfortable position and to take the recommended dose of painkiller (such as paracetamol or ibuprofen).
4. Apply a heat source (e.g., heating pad) to the lower back.
Access help
- Access emergency medical care if the acute lower back pain is severe or the result of a traumatic incident (e.g., a fall or car accident).
- The person should seek medical advice if the back pain:
> is related to an incident that occurred some time ago (e.g., car accident) or they have been experiencing it for four weeks or more
> spreads to one leg, especially if the leg feels weak
> is combined with weak legs, sensory disturbances, or the person experiences bladder or bowel problems, or issues with sexual functionality.
The person should seek medical advice if they have a history of cancer, a weakened immune system, osteoporosis or have used steroids (e.g., prednisolone) for a long time.
Recovery
- If the back pain does not improve within four weeks, seek medical advice.
Education considerations
Context considerations
- Learners may have different beliefs as what lower back pain is and what causes it. Facilitate a discussion to better understand these beliefs.
Facilitation tips and tools
- Emphasise that lower back pain has many different causes (some are common and mild while others can be serious). Helping the person get medical advice is an important first aid action so they can learn how to manage their pain.
- Use scenario-based learning (e.g., a road traffic collision) to practise recognising and managing back pain.
- Facilitators can also make connections to lifting techniques used to reduce the risk of back pain:
- Hold the load firmly.
- Keep the load close to you.
- Lift the load by pushing up with your legs.
- Ensure your legs are stable before moving.
Learning connections
- Connect this topic to Head injury and Spinal injury.
Scientific foundation
Systematic reviews
We used two 2020 evidence summaries from the Centre for Evidence-Based Practice (CEBaP) and three published systematic reviews for this topic.
Prevention
The CEBaP evidence summary looked at the prevention of lower back pain comparing the results of using specific lifting techniques to lift a heavy weight, other lifting strategies or no technique at all. The evidence summary included three randomised controlled trials and three observational studies. It was shown there is a statistically significant association between an increased risk of developing persistent low back pain or symptoms of a herniated lumbar disk and frequent lifting of any load mass with knees straight and the back bent forward.
There is also limited evidence with benefit for lifting with knees bent and back straight. It was shown there is a statistically significant association between a reduced risk of developing symptoms of a herniated lumbar disk and lifting with knees bent and back straight. A statistically significant association between a decreased risk of developing chronic low back pain and occasionally and frequently lifting of any load mass with upright back could not be demonstrated. Statistically significant associations between back pain and lifting posture could not be demonstrated for non-chronic lower back pain.
In addition, there is limited evidence showing no correlation between arm extension or twisting while lifting and the symptoms of a herniated lumbar disk. A statistically significant association between a decreased risk of developing symptoms of a herniated lumbar disk and arm extension or twisting while lifting could not be demonstrated.
Finally, there is limited evidence neither in favour of following a single training session program on low back health nor not following the training program. A statistically significant decrease of back pain, using single training sessions with lifting advice and advice for the prevention of back pain, compared to no training session, could not be demonstrated.
Evidence is of low to very low certainty and results cannot be considered precise due to the low number of events, limited sample size, lack of data and/or large variability of results.
One systematic review indicated that exercise, together with education, is likely to reduce the risk of lower back pain. It also stated that physical activity alone might reduce the risk of a lower back pain episode and subsequent sick leave, at least in the short-term. The available evidence suggested that back belts, shoe insoles, ergonomic equipment or education alone do not prevent lower back pain. Additionally, due to the very low certainty of the evidence, it is unclear whether education, training or ergonomic adjustments prevent sick leave caused by lower back pain (Steffens, 2016).
First aid
Two systematic reviews examined evidence on over-the-counter medication like paracetamol and ibuprofen.
One review looked at the evidence from 65 trials and suggested that NSAIDs effectively provide short-term relief in people with acute and chronic lower back pain without sciatica. However, the effect sizes are small. The evidence did not recommend a specific type of NSAID as being more effective than the others. In the randomised controlled trials, the selective COX-2 inhibitors showed fewer side effects compared to traditional NSAIDs. Still, recent studies have shown that COX-2 inhibitors are associated with increased cardiovascular risks in specific populations (Roelofs, 2008).
The second review shows that there is high-certainty evidence that paracetamol (4 g per day) is no better at improving acute lower back pain in the short or long term, compared to a placebo. Additionally, paracetamol was no better than a placebo on other aspects, such as quality of life and sleep quality. On average, one in five people recounted side effects with no difference between the intervention and control groups. As most of the participants studied were middle-aged, it is unclear if the findings are the same for other age groups (Saragiotto, 2016).
A 2020 evidence summary from CEBaP searched for studies on heat or cold application in case of back pain. Heat treatments include hot water bottles, soft heated packs filled with grain, poultices, hot towels, hot baths, saunas, steam, heat wraps, heat pads, electric heat pads and infra-red heat lamps. Cold treatments include ice, cold towels, cold gel packs, ice packs and ice massage. The review identified four randomised controlled trials from a Cochrane systematic review, and three more recent randomised controlled trials.
No relevant studies were identified for cold application, and thus more research is required on the impact of cold application to improve the symptoms of lower back pain for any duration of time. However, limited evidence was found in favour of heat application. It was shown that heat combined with exercise or education resulted in a statistically significant increase of pain relief and function and a statistically significant decrease of pain intensity and function change scores, compared to exercise or education alone. It was shown that heat resulted in a statistically significant increase of pain relief and a statistically significant decrease of time to pain relief, function change scores, pain and pain affect, compared to no heat.
It was also shown that heat combined with analgesics if needed, resulted in a statistically significant decrease of pain severity in the evenings and percentage of people woken up in the night due to pain compared to analgesics alone.
Evidence is of low certainty and results cannot be considered precise due to limited sample size and/or large variability of results.
Non-systematic reviews
A review of clinical practice guidelines identified several effective, conservative (non-invasive) actions to manage acute and chronic lower back pain. Most high-quality guidelines recommend education, exercise, manual therapy and paracetamol or NSAIDs as first-line treatments for lower back pain. However, the use of paracetamol has been challenged by recent evidence, and this recommendation needs to be updated (Wong, 2017).
Another review identified clinical factors to recognise the conditions of acute lower back pain and sciatica . People with acute back pain experience improvements in the pain, varying levels of disability and usually return to work within one month. Further (but smaller) developments occur up to three months, after which the pain and disability levels remain almost constant. Low levels of pain and disability last from three to at least 12 months. Most people will have at least one recurrence within those 12 months (Pengel, 2003).
References
Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Backpain – Lifting techniques (prevention). Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Backpain – Heat or cold application. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Roelofs P. D., Deyo R. A., Koes B. W., Scholten R. J., Van Tulder M. W. (2008). Non-steroidal anti-inflammatory drugs for low back pain. Cochrane database of systematic reviews, 23 (1).
Saragiotto, B. T., Machado, G. C., Ferreira, M. L., Pinheiro, M. B., Shaheed, C. A., & Maher, C. G. (2016). Paracetamol for low back pain. Cochrane database of systematic reviews, (6).
Steffens, D., Maher, C. G., Pereira, L. S., Stevens, M. L., Oliveira, V. C., Chapple, M., … & Hancock, M. J. (2016). Prevention of low back pain: a systematic review and meta-analysis. The Journal of the American Medical Association internal medicine, 176(2), 199-208.
Non-systematic reviews
Pengel LH, Herbert RD, Maher CG, Refshauge KM. (2003). Acute low back pain: Systematic review of its prognosis. British Medical Journal, 327: 323.
Wong, J.J., Cote, P., Sutton, D.A., et al. (2017). Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMA)Collaboration. Eur J Pain, 21, 201-216.
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Published: 15 February 2021
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