There is no need to recommend bed rest or absence from work, a position supported by Choosing Wisely Canada (Box 1). A Cochrane review found that patients with acute low-back pain experienced small benefits in pain relief and functional improvement from advice to stay active compared with advice to rest in bed.³ There is expert consensus to support the positive link between work and physical, mental and social health.⁴ This patient may need modified work, such as more frequent break periods and avoidance of heavy lifting and bending forward.

What nonpharmacologic therapy should be prescribed for this patient?

There is evidence from systematic reviews to support the use of superficial heat (benefit over placebo, acetaminophen or ibuprofen),⁵ spinal manipulation (benefit over sham therapy),⁶ massage (benefit over inactive control)⁷ and acupuncture (benefit over no treatment)⁸ in patients with acute low-back pain. For flexion-aggravated low-back pain, home exercises are indicated and should include repeated passive extension in the lying position progressing to standing (see link to CORE Back Tool and other useful tools in Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.150660/-/DC1).

Should non-opioid pharmacologic therapy be prescribed for this patient?

Acetaminophen may be prescribed as a therapeutic trial, although recent evidence from randomized trials has shown that it is not effective for reducing pain, disability or recovery time in people with acute low-back pain.⁹ Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed as a therapeutic trial, given that the evidence has shown small improvement in pain intensity.¹⁰ However, Choosing Wisely Canada recommends against prescribing NSAIDs (including cyclo-oxygenase type 2 inhibitors) for patients with hypertension because of potential cardiovascular and renal complications (Box 1). Skeletal muscle relaxants (e.g., methocarbamol) reduce pain and improve function,¹⁰ but common adverse effects include sedation and drowsiness, which could impair this patient’s performance and safety at work.

Should opioids be prescribed for this patient?

Opioids should not be prescribed for intermittent acute back-dominant pain, a position supported by Choosing Wisely Canada (Box 1). Observational studies showed a positive association with opioid use for acute low-back pain and increased work disability in the long term.¹¹ It is well known that opioids can result in euphoria, drowsiness or inability to concentrate, which can negatively affect work status, function and safety to drive a motor vehicle or operate machinery. Patients starting opioid treatment are at risk of continuing them long term, and prolonged use may lead to tolerance and the need for higher doses, opioid dependence or opioid use disorder.¹²

The case revisited

The patient stayed at work on modified duties (avoiding heavy lifting and bending forward). He performed exercises at work and at home (repeated passive extension in the lying position, progressing to the standing position) and applied hot wraps daily. He used acetaminophen at a total daily dose of 3200 mg for one week but reported no additional benefit, so the drug was stopped. A trial of naproxen at the lowest possible dose (250 mg orally twice daily) for two weeks helped him to stay at work and did not increase his blood pressure. He continued to have residual pain (intensity 3/10) for about four months, but he could manage with daily home exercises, heat and weekly massage sessions.