What is the first line treatment for low back pain with a negative Straight Leg Raise (SLR) test?

From the Guidelines

The first-line treatment for low back pain with a negative straight leg test is conservative management, including nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants, as recommended by the American College of Physicians 1. This approach is based on the most recent and highest quality evidence, which suggests that nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation, and pharmacologic treatment with NSAIDs or skeletal muscle relaxants are effective for acute and subacute low back pain 1. Some key points to consider in the management of low back pain with a negative straight leg test include:

• The use of NSAIDs, such as ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily with food), for 1-2 weeks 1
• The addition of muscle relaxants, such as cyclobenzaprine (5-10mg three times daily), for short-term use (7-10 days) if muscle spasms are present 1
• The importance of continued gentle activity, rather than bed rest, to promote recovery and prevent deconditioning 1
• The application of heat or cold packs for 15-20 minutes several times daily to help manage pain and discomfort 1
• The role of physical therapy, focusing on core strengthening exercises, to improve function and reduce pain 1 It is essential to note that the negative straight leg test suggests absence of nerve root compression, making more aggressive interventions unnecessary initially 1. If pain persists beyond 4-6 weeks despite these measures, further evaluation may be warranted to rule out underlying conditions that may require more specific treatment 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

First Line Treatment for Low Back Pain with Negative Straight Leg Test

• The first line treatment for low back pain with a negative straight leg test typically involves the use of medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or muscle relaxants for short-term relief of acute nonspecific low back pain 2.
• NSAIDs are often used in the treatment of low back pain, particularly in people with acute low back pain, and have been shown to be slightly more effective than placebo for short-term pain reduction and global improvement 3, 4.
• The choice of NSAID may depend on the individual patient's medical history and the presence of any contraindications, as different NSAIDs have varying side effect profiles 3, 5.
• It is also important to note that imaging is not typically necessary for uncomplicated low back pain, unless symptoms become protracted or there are specific clinical indications 2, 3.
• In addition to medication, physical therapy options may be considered, and should be matched to the patient's history and exam findings 2.

Medication Options

• Acetaminophen may be used for short-term relief of acute nonspecific low back pain 2.
• NSAIDs, such as ibuprofen or naproxen, may be used for short-term relief of acute nonspecific low back pain 2, 3, 4, 5.
• Muscle relaxants may be used for short-term relief of acute nonspecific low back pain 2.

Important Considerations

• The straight leg raise test is not typically used to diagnose low back pain, but rather to assess for sciatica or lumbar disc herniation 6.
• A negative straight leg test does not rule out the presence of low back pain, and treatment should be based on the individual patient's symptoms and medical history 6.