From the Guidelines
Lumbar strain is diagnosed primarily through clinical evaluation, focusing on localized lower back pain that worsens with movement and may include muscle spasm, with negative neurological findings and no red flags suggesting serious pathology, as recommended by the American College of Physicians and the American Pain Society 1.
Diagnosis
The diagnosis of lumbar strain involves a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement 1. This approach facilitates classification of patients into one of three broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, and back pain potentially associated with another specific spinal cause.
Management
Management begins with conservative measures including:
- Relative rest for 24-48 hours while maintaining some activity
- Ice for the first 48-72 hours followed by heat therapy
- Over-the-counter medications like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs such as ibuprofen (400-800mg three times daily with food) for 7-10 days, as recommended by the American College of Physicians and the American Pain Society 1
- Physical therapy focusing on core strengthening and flexibility should begin within 1-2 weeks of injury
- For moderate pain, muscle relaxants like cyclobenzaprine (5-10mg three times daily for 7-14 days) may be prescribed, though they can cause drowsiness
Prognosis
Most lumbar strains resolve within 2-6 weeks with appropriate management 1. Patients should be educated on proper body mechanics, ergonomics, and regular exercise to prevent recurrence. If pain persists beyond 6 weeks or worsens, or if neurological symptoms develop, further evaluation is warranted to rule out more serious conditions.
Imaging
Imaging is not typically recommended for initial evaluation of lumbar strain, but may be considered if symptoms persist or worsen, or if neurological symptoms develop 1. MRI of the lumbar spine is the preferred imaging modality, as it provides excellent soft-tissue contrast and accurately depicts lumbar pathology, including disc degeneration, as well as the thecal sac and neural structures. CT myelography and radiography may also be useful in certain situations, but are not typically recommended as initial imaging modalities.
From the Research
Lumbar Strain Diagnosis
- Diagnosis of lumbar strain is typically based on a clinical history and physical examination to identify red flags that may indicate serious conditions, as well as yellow flags that indicate risk of disability 2, 3.
- Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy 2.
- The examination should include an evaluation for radicular symptoms 2, 3.
Lumbar Strain Management
- Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 2.
- Pharmacologic interventions are second-line treatment, with nonsteroidal anti-inflammatory drugs (NSAIDs) being the initial medication of choice 2, 3.
- Muscle relaxants, such as cyclobenzaprine, may be beneficial in combination with NSAIDs for acute low back pain with muscle spasm 4, 5.
- Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain 2, 6.
Lumbar Strain Prognosis
- Most patients with chronic low back pain will not require surgery, but evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk 2.
- Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management 6.
- The prognosis for patients with lumbar spinal stenosis is variable, with approximately one-third of patients reporting improvement, approximately 50% reporting no change in symptoms, and approximately 10% to 20% reporting worsening symptoms over time 6.