From the Guidelines
The initial treatment for acute back pain should involve a combination of rest, activity modification, and over-the-counter pain medications, with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line medication options. Patients should limit bed rest to 1-2 days at most, as prolonged immobility can worsen symptoms and delay recovery 1. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen are recommended to reduce inflammation and pain, while acetaminophen is an alternative for those who cannot take NSAIDs 1.
Key Considerations
- Applying ice for the first 48-72 hours (20 minutes on, 20 minutes off) can help reduce inflammation, followed by heat therapy to relax muscles.
- Gentle stretching and walking should be gradually introduced as tolerated, avoiding activities that worsen pain.
- Most acute back pain resolves within 4-6 weeks with conservative management.
Medication Options
- Acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) is a reasonable first-line option for treatment of acute or chronic low back pain because of a more favorable safety profile and low cost 1.
- Nonselective NSAIDs are more effective for pain relief than is acetaminophen, but they are associated with well-known gastrointestinal and renovascular risks 1.
Important Notes
- Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy 1.
- Opioid analgesics or tramadol are an option when used judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled (or is unlikely to be controlled) with acetaminophen and NSAIDs 1.
From the FDA Drug Label
The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.
The initial treatment for acute back pain may include cyclobenzaprine hydrochloride tablets 5 mg, as it has been shown to be effective in clinical trials 2.
- Key points:
- Cyclobenzaprine hydrochloride tablets 5 mg was associated with a greater reduction in palpable muscle spasm than placebo.
- The dose should be tailored to each patient, and may be lowered or raised depending on the severity of symptoms. Alternatively, ibuprofen may be used for mild to moderate pain, with a dose of 400 mg every 4 to 6 hours as necessary for relief of pain 3.
From the Research
Initial Treatment for Acute Back Pain
The initial treatment for acute back pain typically involves a combination of non-pharmacological and pharmacological interventions.
- Stay active and continue ordinary activity within the limits permitted by pain, as advised by studies 4, 5.
- Avoid bed rest, as it is associated with less disability 4.
- Return to work early, which is also associated with less disability 4.
Pharmacological Management
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain 6, 4, 7.
- Topical NSAIDs are recommended for non-low back, musculoskeletal injuries 6.
- Muscle relaxants may be useful for acute low back pain, as adjunctive medications 6.
- NSAIDs are slightly more effective than placebo for short-term pain reduction, disability, and global improvement, but the magnitude of the effects is small and probably not clinically relevant 7.
Non-Pharmacological Interventions
- McKenzie exercises are helpful for pain radiating below the knee 4.
- Patient education, therapeutic exercises, and bracing are also part of conservative management 8.
- Ice for painful areas and stretching exercises may be recommended 4.
- Discuss the use of proper body mechanics and safe back exercises for injury prevention 4.
Imaging and Referral
- Imaging is not usually required, but may be considered if patients have no improvement after 6 weeks 4, 5.
- Referral for goal-directed manual physical therapy may be considered if there is no improvement in 1 to 2 weeks 4.
- Surgery may be indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment 4, 5.