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According to the European guidelines for management of acute nonspecific back pain in primary care, LBP (also known as lumbosacral pain) is “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain”.4 LBP is often categorized by duration of symptoms first, and next by putative etiology. Acute LBP generally lasts less than 6 weeks, subacute LBP lasts 6–12 weeks, and chronic LBP lasts longer than 12 weeks.1 Etiologically, “nonspecific LBP” comprises symptoms not attributable to a known condition (eg, infection, tumor, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome, or cauda equina syndrome). “Recurrent LBP” is defined as a new episode of LBP after a symptom-free period of 6 months, whereas recurrence in less than 6 months is considered as exacerbation of chronic LBP. Within the category of acute LBP, there is sometimes a very brief “hyperacute” period of 24–48 hours during which symptom intensity is so great that sufferers are essentially immobilized, and motion is prevented by pain and intense spasm. Fortunately, this hyperacute LBP is seen in a minority of patients, and generally resolves within 24–48 hours.

The time categorization of LBP is more than academic, in that it is also predictive of prognosis: a high percentage of individuals who progress to chronic LBP will incur long-term disability, with its concomitant economic disadvantages, unemployment, and need for ongoing involvement with the health care system.

LBP is amongst the top ten problems presenting in primary care, whether the population be young adult or senior citizen.1 The lifetime prevalence of LBP is 70%–90% in industrialized countries, and the one-year prevalence is 15%–45%.5 The peak prevalence occurs between the ages of 35 and 55 years. The adult incidence is 5% per year.4 Despite the commonplace presentation of LBP, clinicians may feel some uncertainty regarding optimal symptomatic management.

The natural history of acute LBP indicates that, even in the absence of treatment, up to 70% of acute LBP cases are resolved within 3 weeks, and up to 90% by 12 weeks.6–12 Unfortunately, 2%–7% of acute LBP cases develop chronic pain, accounting for up to 75%–85% of total worker absenteeism.13

The most common risk factors for LBP are previous LBP, heavy physical work (frequent bending, twisting, lifting, pulling, pushing) sedentary lifestyle, workplace vibrations, psychosocial risk factors (stress, distress, anxiety, depression, cognitive functioning, pain behavior), job dissatisfaction, mental stress at work, smoking, obesity, and lack of exercise.4 The clinician’s task is to exclude the red flags (like age at onset of pain55 years, weight loss, neurologic changes, significant trauma, or chest pain), inform the patient of the generally benign nature of the disorder, encourage physical activity, and reduce pain to enhance mobility, allowing maximum opportunity for return to work as quickly as possible. NSAIDs are one of the pharmacotherapeutic tools which can be used during this process.

Nonsteroidal anti-inflammatory drugs

It appears that NSAIDs have been used to manage musculoskeletal symptoms since antiquity. Although sodium salicylate (a derivative of various plants, such as willow bark), was probably the first NSAID, gastrointestinal side effects precluded its widespread use.