What are the treatment options for acute lower back pain?

From the Guidelines

For acute back pain treatment, spinal manipulation administered by providers with appropriate training is associated with small to moderate short-term benefits, and should be considered as a first-line nonpharmacologic therapy. When it comes to pharmacologic treatment, over-the-counter pain medications like ibuprofen (400-600mg every 6-8 hours) or acetaminophen (500-1000mg every 6 hours) can be used to reduce pain and inflammation 1. It's essential to note that systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1.

Some key points to consider in the treatment of acute back pain include:

• Avoiding activities that worsen pain, but not staying completely immobile, as this can delay recovery
• Applying ice packs for 15-20 minutes several times daily during the first 48 hours, then switching to heat therapy using warm compresses or heating pads for 15-20 minutes to relax muscles
• Gentle stretching and movement should begin as soon as tolerable
• Considering using topical analgesics like menthol creams for additional relief
• Maintaining good posture and using proper body mechanics when sitting, standing, and lifting

According to a 2017 systematic review, several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain, including mind–body interventions 1. However, for acute low back pain, the evidence suggests that spinal manipulation is a viable treatment option, with benefits ranging from small to moderate 1.

It's crucial to seek medical attention immediately if the pain is severe, persists beyond 1-2 weeks, includes leg weakness/numbness, or is accompanied by fever or bladder/bowel problems, as these may indicate a more serious condition requiring professional evaluation. Most acute back pain episodes resolve within 4-6 weeks with conservative measures, as they address muscle tension, inflammation, and promote natural healing processes.

From the FDA Drug Label

Clinical Studies Eight double-blind controlled clinical studies were performed in 642 patients comparing cyclobenzaprine hydrochloride 10 mg, diazepam, and placebo. Muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living were evaluated The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. One study compared cyclobenzaprine hydrochloride tablets 5 and 10 mg t.i. d. to placebo; and a second study compared cyclobenzaprine hydrochloride tablets 5 and 2.5 mg t.i. d. to placebo. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

Acute Back Pain Treatment: Cyclobenzaprine hydrochloride tablets, specifically the 5 mg dose, have been shown to be effective in treating acute back pain, as demonstrated by statistically significant superiority over placebo for primary endpoints such as global impression of change, medication helpfulness, and relief from starting backache 2.

• The medication has been associated with a greater reduction in palpable muscle spasm than placebo.
• The overall effectiveness of cyclobenzaprine was similar to that observed in the double-blind controlled studies.

From the Research

Acute Back Pain Treatment

• The American College of Physicians (ACP) recommends nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic low back pain 3.
• For acute low back pain, primary care providers (PCPs) typically provide advice to stay active (81%) and pharmacologic management (97%; primarily nonsteroidal anti-inflammatory drugs) 3.
• The best approach to acute low back pain includes advising patients to stay active, continue ordinary activity within the limits permitted by pain, avoid bed rest, and return to work early 4.
• Consideration of McKenzie exercises, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended if medication is necessary 4.
• A study comparing cyclobenzaprine 5 mg three times daily (TID) orally as monotherapy or in combination with ibuprofen 400 mg TID or 800 mg TID found that all three treatment groups demonstrated significant improvements from baseline in patient global impression of change, spasm, pain, and medication helpfulness 5.
• 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, utilizing drugs with proven efficacy and minimal side effects, and continued activity rather than bed rest 6.
• First-line pharmacologic agents for acute low back pain are acetaminophen and NSAIDs, while muscle relaxants can be used for spasms and pain reduction, and opioids should be minimized 6.
• Patient education and medications such as nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants are beneficial for nonspecific acute low back pain, and bed rest should be avoided if possible 7.

Treatment Options

• Nonpharmacologic treatments:
  • Physical therapy
  • Chiropractic care
  • Massage therapy
  • Acupuncture
• Pharmacologic treatments:
  • Acetaminophen
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Muscle relaxants
  • Opioids (minimized)
• Other treatments:
  • McKenzie exercises
  • Spine stabilization exercises
  • Spinal manipulation
  • Thermotherapy
  • Cryotherapy
  • Transcutaneous electrical nerve stimulation (TENS)