Back Pain : What are the treatments for a bout of non-specific low back pain?

What are the treatments for a bout of non-specific low back pain?
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The following advice and treatment is commonly given for a sudden acute bout of non-specific low back pain.

Exercise and keep going
Continue with normal activities as much as possible. This may not be possible at first if the pain is very bad. However, move around as soon as you are able, and get back into normal activities as soon as you can. As a rule, don't do anything that causes a lot of pain. However, you will have to accept some discomfort when you are trying to keep active. Setting a new goal each day may be a good idea. For example, walking around the house on one day, a walk to the shops the next, etc.

Also, sleep in the most naturally comfortable position on whatever is the most comfortable surface. Advice given in the past used to be to sleep on a firm mattress. However, there is no evidence to say that a firm mattress is better than any other type of mattress for people with low back pain. Some people find that a small firm pillow between the knees when sleeping on the side helps to ease symptoms at night.

If you have a job, aim to get back to work as soon as possible. There is no need to wait for complete freedom from pain before returning to work. Returning to work often helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.

In the past, advice had been to rest until the pain eases. It is now known that this was wrong. The evidence from research trials is that you are likely to recover more quickly by getting moving again, and getting back to work as soon as possible. Also, you are less likely to develop chronic (persistent) back pain if you keep active when you have back pain rather than rest a lot.

Medication
If you need painkillers, it is best to take them regularly. This is better than taking them now and again just when the pain is very bad. If you take them regularly the pain is more likely to be eased for much of the time and enable you to exercise and keep active.

Paracetamol is often sufficient if you take it regularly at full strength. For an adult, this is 1000 mg (usually two 500 mg tablets), four times a day.
Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac or naproxen need a prescription. Some people may not be able to take anti-inflammatories. For example, some people with asthma, high blood pressure, kidney failure, or heart failure.
A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. This may make back pain worse if you need to strain to go to the toilet. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
A muscle relaxant such as diazepam is occasionally prescribed for a few days if the back muscles become very tense and make the pain worse.
Other treatments
Heat such as a hot bath may help to ease pain.

Treatment may vary, and the situation should be reviewed by a doctor if the pain becomes worse, or if the pain persists beyond 4-6 weeks, or if symptoms change. Other pain relieving techniques may be tried if the pain becomes chronic (persistent).

What is the outlook (prognosis)
Most of us (about 8 in 10 people) will have a bout of non-specific low back pain at some point in our life. The severity can vary. However, it is difficult to quote exact figures as to outlook. This is partly because it is so common and many people with back pain do not consult a doctor. Roughly, it is thought that:

Most non-specific back pains ease and go quickly, usually within a week or so.
In about 7 in 10 cases, the pain has either gone or has greatly eased within four weeks.
In about 9 in 10 cases the pain has gone or has greatly eased within six weeks.
However, once the pain has eased or gone it is common to have further bouts of pain (recurrences) from time to time in the future. Also, it is common to have minor pains on and off for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer. This is called chronic back pain.

Chronic (persistent) non-specific low back pain
Non-specific low back pain is classed as chronic (persistent) if it lasts longer than six weeks. In some people it lasts for months, or even years. Symptoms may be constant. However, the more usual pattern is where symptoms follow an irregular course. That is, reasonably long periods of mild or moderate pain may be interrupted by bouts of more severe pain.

What is the treatment for chronic non-specific low back pain
Initial treatment is similar to acute attacks. That is, aim to keep as active as possible. Also, painkillers can help. In addition to the painkillers listed above, your doctor may advise a course of an antidepressant medicine in the tricyclic group, for example, amitriptyline. Tricyclic antidepressants have other actions separate to their action on depression. They are used in a variety of painful conditions, including back pain.

Also, a national guideline (from NICE - referenced below) recommends one or more of the following treatments should be considered. Each of these treatments has some evidence from research trials to suggest that they will help to ease symptoms in some people (but not all):

Structured exercise programme. This means a programme of exercise supervised by a professional such as a physiotherapist. This is likely to be in a group setting. Exercises may include aerobic activity, movement instruction, muscle strengthening, posture control and stretching. It typically consists of up to eight supervised sessions over 8-12 weeks with encouragement to keep on doing the exercises at home between sessions.
Manual therapy. Typically this includes several sessions of massage, spinal mobilisation and/or spinal manipulation. With spinal mobilisation the therapist moves the joints of the spine around in their normal movement range. In spinal manipulation, the therapist moves joints beyond the usual range of movement.
A course of acupuncture. It is not clear how this may work. (Some doctors feel that this is a controversial recommendation as the evidence for effectiveness is weak.)
Cognitive behaviour therapy (CBT) may also be recommended as a treatment option. There is good evidence from research trials that it can help. CBT aims to help you to change the way that you think, feel and behave. It is used as a treatment for various health problems including various types of chronic pain.

If the above treatments have not helped much then you may be referred to a specialist pain clinic. Rarely, a surgical operation called spinal fusion is considered when all other treatment options have not helped and pain remains constant and severe.

Can further bouts of back pain be prevented?
Evidence suggests that the best way to prevent bouts of low back pain is simply to keep active, and to exercise regularly. This means general fitness exercise such as walking, running, swimming, etc. There is no firm evidence to say that any particular back strengthening exercises are more useful to prevent back pain than simply keeping fit and active. It is also sensible to be back aware. For example, do not lift objects when you are in an awkward twisting posture.