What is the recommended management for acute lower back pain with a normal physical examination?

From the Guidelines

For acute back pain with a normal physical exam, initial management should focus on conservative measures, with a strong recommendation to remain active within pain limits rather than bed rest, as prolonged immobility can worsen symptoms, as suggested by the American College of Physicians and the American Pain Society 1. The goal of these measures is to reduce inflammation, relieve muscle tension, and support the body's natural healing processes while maintaining functional movement patterns.

• First-line medications include acetaminophen (500-1000mg every 6 hours, not exceeding 4g daily) or NSAIDs such as ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily with food) for 7-10 days.
• Apply heat therapy for 15-20 minutes several times daily to relax muscles and improve blood flow.
• Consider muscle relaxants like cyclobenzaprine (5-10mg at bedtime) for severe muscle spasm, but only for short periods (3-7 days) due to sedation effects.
• Physical therapy focusing on gentle stretching and core strengthening can be initiated after the acute phase subsides. Most acute back pain resolves within 4-6 weeks with these measures. Red flags warranting immediate medical attention include severe or worsening pain, neurological symptoms (numbness, weakness, bowel/bladder changes), fever, or history of cancer, trauma, or immunosuppression. It is essential to inform patients of the generally favorable prognosis of acute low back pain and the importance of remaining active, as well as providing information about effective self-care options, as recommended by the guidelines 1.

From the Research

Management of Acute Back Pain

The management of acute back pain with a normal physical exam involves several approaches, including medication, physical therapy, and education.

• Medication: The use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen is recommended as first-line treatment for acute low back pain 2, 3. Acetaminophen can also be used, but the addition of acetaminophen to ibuprofen does not improve outcomes within 1 week 3. Muscle relaxants like cyclobenzaprine may be used for spasms and pain reduction, but their effectiveness is debated 2, 4. Opioids should be minimized due to their potential for dependence and side effects 5.
• Physical Therapy: Early physical therapy (PT) is associated with statistically significant reductions in short-term pain and disability, although the effect sizes are small 6. The timing of PT does not seem to have a significant impact on long-term outcomes, but early intervention may be beneficial for short-term pain and disability management.
• Education and Rehabilitation: Patient education on proper back care, posture, and lifting techniques is essential for managing acute back pain 2, 5. Continued activity, rather than bed rest, is recommended to reduce pain and improve functional status 5. Other adjuncts like thermotherapy, cryotherapy, transcutaneous electrical nerve stimulation (TENS), spinal manipulative therapy, and acupuncture may also be used to improve acute low back pain 5.

Key Findings

• The combination of cyclobenzaprine or oxycodone/acetaminophen with naproxen does not improve functional outcomes or pain at 1-week follow-up 2.
• Cyclobenzaprine 5 mg three times daily is not superior to combination therapy with ibuprofen for acute neck or back pain with muscle spasm 4.
• The World Federation of Neurosurgical Societies (WFNS) Spine Committee recommends a uniform approach to the treatment of acute low back pain, including proper patient education and the use of drugs with proven efficacy and minimal side effects 5.
• Early physical therapy is associated with significant reductions in short-term pain and disability, but the effect sizes are small 6.