From the Guidelines
For patients with low back pain, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation as the first line of treatment. This approach is supported by the American College of Physicians' clinical practice guideline, which recommends nonpharmacologic treatment for acute, subacute, and chronic low back pain 1. The guideline suggests that patients with acute or subacute low back pain improve over time regardless of treatment, and therefore, nonpharmacologic treatment should be the initial approach.
Some of the nonpharmacologic treatments that can be considered as the first line of treatment include:
- Superficial heat (moderate-quality evidence)
- Massage
- Acupuncture
- Spinal manipulation (low-quality evidence)
- Exercise, multidisciplinary rehabilitation, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy for patients with chronic low back pain 1.
If pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants should be considered as the first line of pharmacologic treatment (moderate-quality evidence) 1. However, it is essential to note that pharmacologic treatment should only be considered after nonpharmacologic treatment has been tried, and the patient's symptoms persist.
It is also crucial to avoid prolonged bed rest, as it can worsen stiffness and weakness, and to consider medical evaluation if pain persists beyond 4-6 weeks or is accompanied by red flags such as fever, unexplained weight loss, bowel/bladder dysfunction, or leg weakness.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION ... Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain. The first line treatment for low back pain is ibuprofen (PO) 400 mg every 4 to 6 hours as necessary for relief of pain 2.
- The recommended dose is 400 mg every 4 to 6 hours.
- Do not exceed 3200 mg total daily dose.
- The dose should be tailored to each patient, and may be lowered or raised depending on the severity of symptoms.
From the Research
First-Line Treatment for Low Back Pain
- The first-line treatment options for low back pain include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4
- For acute low back pain, pharmacologic management with NSAIDs is commonly recommended by primary care providers 5
- Nonpharmacologic treatments, such as physical therapy, chiropractic care, and massage therapy, are often recommended for chronic low back pain 5
- The choice of treatment should be individualized and based on the patient's specific needs and medical history 3, 4
Pharmacologic Options
- Acetaminophen is a well-tolerated option for mild to moderate pain, but lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 3
- NSAIDs are effective for pain relief, but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 3, 4
- Opioids may be considered for severe or refractory acute pain, but their use should be minimized due to the risk of addiction and other adverse effects 3, 6