What is the recommended treatment for musculoskeletal lower back pain?

From the Guidelines

The recommended treatment for musculoskeletal lower back pain typically begins with conservative measures including rest, activity modification, and over-the-counter pain medications, with a focus on nonpharmacologic therapy with proven benefits, such as spinal manipulation for acute low back pain and intensive interdisciplinary rehabilitation for chronic or subacute low back pain, as recommended by the American College of Physicians and the American Pain Society 1.

Key Considerations

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are often effective for reducing inflammation and pain, while acetaminophen can be used if NSAIDs are contraindicated.
• Physical therapy focusing on core strengthening exercises, stretching, and proper body mechanics should be initiated within 1-2 weeks of pain onset.
• Heat therapy and ice may be used to relax muscles and reduce inflammation in acute phases.
• Muscle relaxants like cyclobenzaprine may be prescribed for short-term use if muscle spasms are present.
• 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.

Nonpharmacologic Therapy

• Spinal manipulation is associated with small to moderate short-term benefits for acute low back pain.
• Intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for chronic or subacute low back pain.
• Herbal therapies, such as devil's claw, willow bark, and capsicum, seem to be safe options for acute exacerbations of chronic low back pain, but benefits range from small to moderate.

Important Notes

• Extended courses of medications should generally be reserved for patients clearly showing continued benefits from therapy without major adverse events.
• Further evaluation by a healthcare provider is recommended if pain persists beyond 4-6 weeks despite these interventions to rule out more serious conditions.
• Depression is common in patients with chronic low back pain and should be assessed and treated appropriately 1.

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. Analysis of the data from controlled studies shows that cyclobenzaprine produces clinical improvement whether or not sedation occurs.

The recommended treatment for musculoskeletal lower back pain is cyclobenzaprine hydrochloride tablets. The dosage is 5 mg or 10 mg t.i.d., with the 5 mg dose being statistically significant for all three primary endpoints at day 8. Cyclobenzaprine can be used in combination with other analgesics, such as naproxen or aspirin, but with caution due to potential increased side effects, such as drowsiness 2.

From the Research

Treatment Options for Musculoskeletal Lower Back Pain

The treatment of musculoskeletal lower back pain can vary depending on the underlying cause and severity of the condition. Some studies suggest the following treatment options:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as first-line medications for chronic low back pain 3, 4, 5, 6
• Muscle relaxants and narcotic analgesics may be appropriate for some patients, but selection criteria are unclear 4
• Epidural steroid injections may benefit patients with radicular symptoms, but studies have produced mixed results 5
• Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipulation are effective in certain clinical situations 5
• Mesenchymal Stem Cell (MSC) injection into the lumbar facet joints and epidural space may result in significant improvement of lower back pain 7

Medication Management

Medications are the most commonly used type of treatment for low back pain. The choice of medication depends on the individual patient's needs and the potential benefits and risks associated with each medication. Some studies recommend:

• Paracetamol (acetaminophen) and NSAIDs as first-line options for pain relief 6
• Opioids as more potent analgesics, but not as a first-line option due to their abuse potential 6
• Skeletal muscle relaxants and benzodiazepines as adjunctive medications for acute low back pain, but with a high incidence of sedation 6
• Tricyclic antidepressants as an option for chronic low back pain, but with small or uncertain effects on pain 6

Non-Pharmacological Interventions

Non-pharmacological interventions can also be effective in managing musculoskeletal lower back pain. Some studies suggest:

• Exercise therapy as an effective treatment for chronic low back pain 5
• Multidisciplinary rehabilitation programs as an effective treatment for chronic low back pain 5
• Acupuncture as an effective treatment for chronic low back pain 5
• Spinal manipulation as an effective treatment for acute low back pain 5