From the Guidelines
Outpatient treatment for elderly patients with lumbar strain should prioritize a multimodal approach, including conservative measures, medication, physical therapy, and education, to minimize risks and optimize pain management and functional recovery. The treatment should begin with conservative measures, including rest for 24-48 hours, followed by gradual return to activity, as recommended by the American College of Physicians and the American Pain Society 1.
Medication
- Acetaminophen is the first-line medication, starting at 500-650mg every 6 hours (maximum 3000mg daily), due to its favorable safety profile in the elderly, as it is a slightly weaker analgesic than NSAIDs but has a more favorable safety profile and low cost 1.
- NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (250-500mg twice daily) can be used for short courses (5-7 days) if acetaminophen is insufficient, but with caution due to increased risk of gastrointestinal, renal, and cardiovascular side effects in older adults 1.
- Muscle relaxants such as cyclobenzaprine (5mg once or twice daily) may be prescribed for short periods (3-7 days) but can cause sedation and confusion in elderly patients.
Physical Therapy and Education
- Physical therapy focusing on gentle stretching, core strengthening, and proper body mechanics should be initiated within 1-2 weeks of injury.
- Patients should be educated on proper posture, ergonomics, and lifting techniques to prevent recurrence.
- Heat therapy (20 minutes several times daily) can help relieve muscle spasms, while cold packs may reduce inflammation in the acute phase.
This approach is supported by the American College of Physicians and the American Pain Society, which recommend providing patients with evidence-based information on low back pain, advising patients to remain active, and providing information about effective self-care options 1. By prioritizing a multimodal approach, clinicians can minimize medication-related risks in elderly patients and optimize pain management and functional recovery.
From the Research
Outpatient Treatment Options for Elderly Lumbar Strain
The following are recommended outpatient treatment options for elderly patients with lumbar strain:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute low back pain, with adjustments for gastrointestinal and renal risk factors 2
- Acetaminophen for patients with acute back pain, with efforts to minimize costs and complications 3
- Muscle relaxants for some patients, but selection criteria are unclear, and these drugs should be prescribed for fixed periods 3
- Tramadol for patients who do not respond to NSAIDs, but with consideration of its risks of cognitive and classic opioid side effects 2, 4
- Gabapentin and pregabalin for neuropathic pain, with mixed evidence for their effectiveness 2
- Antispastic and antispasmodic muscle relaxants for myofascial-based pain 2
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) for neuropathic pain, with a more favorable safety profile than tricyclic antidepressants (TCAs) 2
Non-Pharmacological Interventions
Non-pharmacological interventions that may be effective for elderly patients with lumbar strain include:
- Acupuncture 5
- Exercise therapy 5
- Multidisciplinary rehabilitation programs 5
- Massage 5
- Behavior therapy 5
- Spinal manipulation 5
Considerations for Elderly Patients
When treating elderly patients with lumbar strain, it is essential to consider their reduced liver and renal function, comorbid medical problems, and polypharmacy 2. The goal is to employ the lowest therapeutic doses and minimize adverse events. Opioids are typically avoided in the treatment of spine-related pain in older adults due to their morbidity and mortality risk and are reserved for refractory severe pain 2.