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Short Summary
Main recommendation: For acute back pain, follow a four-part conservative plan based on the Saskatchewan Spine Pathway: pain-relieving positions, movement exercises, medication, and optional heat or cold, with reassurance that most patients improve within two to three weeks. The pathway classifies patients into one of four pain patterns, each with its own specific positions and exercises. It is not meant for serious causes such as osteomyelitis or cauda equina syndrome.
Key Points
- Reassurance matters: about 90% of patients with acute back pain seen within the first three days recover within two to three weeks, so the plan should emphasize expected improvement.
- The four patterns are: back pain worse with flexion (pattern one), back pain worse with extension (pattern two), constant leg-dominant pain from herniated disc (pattern three), and intermittent leg-dominant pain from spinal stenosis, usually over age 50 (pattern four).
- Naming a specific pattern-based diagnosis may make patients more confident in their provider and more willing to try conservative care.
- Medication is modest: acetaminophen and NSAIDs are first-line and reduce back pain by an estimated 10 to 20%.
- The video recommends re-evaluating patients in the office after seven to 10 days; for those with no improvement, video number four in the series describes options for specialty referral, specifically physical therapy.
Details Worth Noting
- Concrete instructions:
- Positions to relieve pain:
- Patterns one and two: Z position (lie flat, head on a pillow, feet on a chair with knees at 90 degrees) and knees-to-chest (bring knees to chest, wrap arms around them and pull toward chest; one leg at a time is easier).
- Pattern three: Z lie and resting on hands and knees.
- Pattern four: sitting flexion (sit forward in a chair, feet flat and hip-width apart, rest stomach on lap, let head and arms hang toward feet).
- Movement exercises (after a few days of positions):
- Pattern one: sphinx push-up. Lie on stomach, hands in front, keep lower body on floor, slowly raise upper body with arms, fully extend elbows, slowly lower; repeat 10 times.
- Pattern two: trunk flexion. Kneel on hands and knees, tuck chin, arch back, slowly sit back on heels letting shoulders drop toward the floor, keep back relaxed, hold 60 seconds.
- Pattern three: no movement exercises recommended.
- Pattern four: core and hip-flexion strengthening, plus pelvic tilt (on back, knees bent, feet flat hip-width apart with knees slightly closer than feet; tighten abdominals and press lower back to the floor).
- Heat or cold: heat via hot packs, warm blankets, or a heating pad on low or medium; cold via a wet towel frozen for 15 minutes or a bag of frozen vegetables (less evidence supports ice).
- Medication: opioids are not recommended for acute back pain; if prescribed, use only at night for four weeks or less. Muscle relaxants may be used for four weeks or less if sedation or dizziness is tolerable.
- Positions to relieve pain:
- Pictures of the positions and exercises are available for providers to add to the patient instruction field on the After Visit Summary and Care Connect, with four documents matching the four patterns.
- The pathway excludes serious causes such as osteomyelitis and cauda equina syndrome.
- Continue conservative care for improving patients even if pain is not fully resolved.
Bottom Line
Most acute back pain resolves on its own within weeks, so a structured conservative plan with clear, pattern-matched instructions and a recheck at seven to 10 days is the standard approach, with physical therapy as the next step if there is no improvement.
