Ditch Bed Rest: New Standards for Simple Back Pain Recovery

New guidance on managing acute low back pain encourages clinicians to take an active role in managing recovery before turning to more intensive treatments.The new guideline from the American Academy of Pain Medicine, published in the journal Pain Medicine, emphasizes movement, heat therapy, and over-the-counter medications.“We tried to prioritize the self-management aspect of caring for acute low back pain to try to empower patients to understand that there is a lot they can do to get the ball rolling on recovery,” said Devan Kansagara, MD, professor of medicine at Oregon Health & Science University in Portland, Oregon, and co-chair of the guideline panel.The US has among the highest costs associated with managing low back pain, with annual healthcare expenditures estimated at $40 billion a year, or about $2,000 per patient. Most patients with low back pain do not have an identifiable underlying cause.Self-ManagementThe new guidance defines acute low back pain as pain lasting 6 weeks or less, with an episode persisting for more than 24 hours that is preceded and followed by at least 1 month without pain.A recommended first step is for clinicians to provide education that low-impact movement is safe and important for recovery, and that usual exercises should be adjusted based on pain. Applying artificial heat to the affected area can be effective, as is the use of over-the-counter nonsteroidal anti-inflammatory medications (NSAIDs).“We’ve learned that bed rest is probably going to prolong the recovery and make things worse,” Kansagara said.If symptoms do not improve after 2 weeks of self-management, clinicians may recommend prescription-strength NSAIDs, skeletal muscle relaxants, physical therapy, or acupuncture. Clinicians may also consider prescribing a short course of systemic steroids or referring patients for epidural steroid injections. Carisoprodol is not recommended due to safety issues.The guidance panel does not recommend the routine prescribing of opioids to manage acute low back pain. Such drugs should be used only in select cases when the potential benefits outweigh known risks, including addiction and overdose.The position aligns with a broader effort across the medical community to reduce inappropriate prescribing in the wake of the opioid crisis. Public health experts have linked overprescribing of opioids such as oxycodone over the past three decades to a sharp rise in drug overdose deaths nationwide.“We want clinicians to still retain the decision-making capacity to judge when it might be appropriate,” Kansagara said. “But it’s certainly not a good routine initial treatment for low back pain.”The guidance also advises to not routinely obtain imaging in those without traumatic, acute back pain that has lasted for less than 6 weeks, unless they present with symptoms or risk factors of a potentially serious spinal cause.While the guidance reflects many of the clinical practices that have become standard in the care of low back pain, it also raises questions about whether patients seeking relief will embrace a more limited treatment approach, said Puneet Aggarwal, MD, pain and sports medicine specialist and site medical director at Advocate Health in Charlotte, North Carolina, who was not involved in the guidance.He suggested clinicians listen closely to patient concerns to ensure they feel supported and that their needs are being met.“The majority of patients that come to our clinics are looking for a diagnosis, an understanding of why they are having low back pain, the timeline of how long their symptoms would likely last, and what they can do to prevent a recurrence of symptoms,” Aggarwal said. “Taking the time to listen to their story, understand their symptoms, answering their questions, and addressing their concerns often leads to high patient satisfaction.”The project was funded by support from the FDA. No conflicts of interest were reported.Steven Ross Johnson is a journalist who covers public health and healthcare delivery issues.