What is the recommended treatment for back spasm?

Treatment for Back Spasm

Skeletal muscle relaxants, particularly cyclobenzaprine, are the recommended first-line treatment for back spasm, providing moderate superiority to placebo for short-term pain relief, with patients nearly 5 times more likely to report improvement by day 14 compared to placebo. 1, 2

Pharmacological Management

First-Line Options:

1. Muscle Relaxants

   • Cyclobenzaprine 5-10 mg three times daily for up to 2-3 weeks 3, 1
   • Should only be used short-term (2-3 weeks maximum) as effectiveness for longer periods is not established 3
   • Provides moderate pain relief within 2-4 days 4
   • Extended-release formulations may reduce daytime drowsiness 5

2. NSAIDs

   • Most effective first-line option for acute back pain 1
   • No evidence that any specific NSAID is superior to others 1
   • Can be used alone or in combination with muscle relaxants 6

Combination Therapy:

• Combining cyclobenzaprine with NSAIDs (like naproxen) may provide better relief of objective muscle spasm, tenderness, and greater spinal motion than NSAIDs alone 6
• However, some studies show combination therapy with cyclobenzaprine plus ibuprofen is not superior to cyclobenzaprine alone 7

Non-Pharmacological Management

• Heat Application: Heating pads or heated blankets for acute back pain 1
• Physical Activity: Patients should remain active and continue normal daily activities as much as pain allows 1
• Self-Care Education: Provide reassurance about generally favorable prognosis and advice to stay active despite some discomfort 1
• Exercise Therapy: Consider starting after the acute phase (2-6 weeks) 4

Important Considerations and Precautions

Side Effects of Muscle Relaxants:

• Central nervous system events (somnolence, fatigue, lightheadedness) are common 4
• Higher total number of adverse events compared with placebo (RR, 1.50) 4
• Central nervous system adverse events are more common (RR, 2.04) 4
• Most events are self-limited and serious complications are rare 4

Special Populations:

• Elderly patients: Use lower doses (2.5-5 mg) of muscle relaxants due to increased sensitivity to sedative effects 1
• Hepatic impairment: Use cyclobenzaprine with caution; avoid in moderate to severe impairment 1
• Patients who need to remain alert: Consider lower doses or extended-release formulations 1, 5

Treatment Duration and Follow-up

• Muscle relaxants should only be used for short periods (up to 2-3 weeks) 3, 1
• Treatment efficacy is greatest early (first few days) and declines after the first week 2
• Consider follow-up within 1-2 weeks to assess response to treatment 1

Interventions to Avoid

• Long-term use of muscle relaxants beyond 2-3 weeks 1
• Extended bed rest (can worsen outcomes) 1
• Routine diagnostic imaging for uncomplicated back pain 1
• Using opioids as first-line therapy 1
• Systemic corticosteroids (not more effective than placebo) 1

When to Consider Specialist Referral

Consider consultation with a back specialist when patients do not respond to standard noninvasive therapies, though there is insufficient evidence to guide specific recommendations on timing or indications for referral 4.