What is the management of acute lower back pain?

From the Guidelines

Management of acute back pain primarily involves conservative measures, with a focus on nonpharmacologic treatments such as superficial heat, massage, acupuncture, or spinal manipulation, as recommended by the American College of Physicians in 2017 1. The goal of treatment is to reduce inflammation, relieve muscle tension, and allow natural healing processes to occur while maintaining functional movement patterns that prevent deconditioning. Some key points to consider in the management of acute back pain include:

• Providing patients with evidence-based information on low back pain, including its expected course and effective self-care options, as recommended by the American College of Physicians and the American Pain Society in 2007 1.
• Advising patients to remain active, as this is more effective than resting in bed for patients with acute or subacute low back pain, as noted in the 2007 guideline 1.
• Considering the use of medications with proven benefits, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), in conjunction with back care information and self-care, as recommended in the 2007 guideline 1.
• Avoiding prolonged bed rest, which can worsen symptoms, and instead encouraging gentle stretching and gradual return to normal activities as pain allows.
• Considering physical therapy focusing on core strengthening exercises once acute pain subsides, as this can be beneficial for long-term management. It's essential to note that most acute back pain resolves within 4-6 weeks with conservative measures, and patients should seek immediate medical attention if they experience severe pain, neurological symptoms, fever, or if pain follows trauma. The 2017 guideline from the American College of Physicians 1 provides strong recommendations for the management of acute back pain, including the use of nonpharmacologic treatments and the consideration of pharmacologic treatments, such as NSAIDs or skeletal muscle relaxants, if desired. Overall, the management of acute back pain should prioritize conservative measures, with a focus on nonpharmacologic treatments and patient education, to reduce morbidity, mortality, and improve quality of life.

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.

Management of Acute Back Pain:

• Cyclobenzaprine hydrochloride tablets 5 mg was demonstrated to be effective in the management of acute back pain in two double-blind, controlled clinical trials.
• The primary endpoints of global impression of change, medication helpfulness, and relief from starting backache were significantly improved with cyclobenzaprine hydrochloride tablets 5 mg compared to placebo.
• Physician-assessed secondary endpoints also showed that cyclobenzaprine hydrochloride tablets 5 mg was associated with a greater reduction in palpable muscle spasm than placebo 2.

From the Research

Management of Acute Back Pain

• The management of acute back pain involves a combination of non-pharmacologic and pharmacologic approaches, with a focus on staying active and avoiding bed rest 3, 4, 5.
• First-line pharmacologic agents for acute back pain include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with muscle relaxants and opioids used as adjuncts or for severe cases 3, 6, 5.
• Non-pharmacologic treatments, such as physical therapy, chiropractic care, massage therapy, and acupuncture, may be recommended for chronic low back pain, but are not typically used for acute symptoms 7.
• Patient education and proper body mechanics are also important components of acute back pain management, with a focus on preventing future episodes and reducing disability 3, 4, 5.

Pharmacologic Management

• Acetaminophen and NSAIDs are recommended as first-line treatments for acute mild to moderate pain, with topical NSAIDs used for non-low back musculoskeletal injuries 6.
• Muscle relaxants may be used for acute low back pain, particularly for spasms and pain reduction, while opioids should be minimized due to the risk of addiction and other adverse effects 6, 5.
• The choice of pharmacologic agent should be tailored to the individual patient, taking into account their medical history, treatment expectations, and potential side effects 6.

Non-Pharmacologic Management

• Staying active and continuing ordinary activity within the limits permitted by pain is recommended, with bed rest avoided due to its association with increased disability 3, 4, 5.
• Lumbar spine orthotics may be used to reduce pain and augment functional status, while thermotherapy, cryotherapy, transcutaneous electrical nerve stimulation (TENS), spinal manipulative therapy, and acupuncture may be used as adjuncts to improve acute low back pain 5.
• Patient education and proper body mechanics are important components of non-pharmacologic management, with a focus on preventing future episodes and reducing disability 3, 4, 5.