What is the best treatment for back pain spasms?

Treatment of Back Pain Spasms

For back pain spasms, the most effective approach is a stepped care strategy starting with non-pharmacological treatments such as local heat application and maintaining tolerable physical activity, followed by acetaminophen or NSAIDs if needed, with muscle relaxants like cyclobenzaprine considered as adjunctive therapy for short-term use only (up to 2-3 weeks). 1

First-Line Management

Non-Pharmacological Approaches

• Apply local heat to the affected area - demonstrated moderate efficacy 1
• Maintain tolerable physical activity and avoid prolonged bed rest 1
• Education on self-care and body mechanics 1
• Supervised exercise programs with individually tailored stretching and strengthening exercises 1

First-Line Medications

• Acetaminophen (up to 3000mg/day) due to its favorable safety profile 1
• NSAIDs (like ibuprofen, naproxen) if acetaminophen provides insufficient relief 1
  • Monitor for adverse effects, especially in elderly patients
  • Moderate-quality evidence shows NSAIDs provide small to moderate pain improvement compared to placebo 2

Second-Line Management

Muscle Relaxants

• Cyclobenzaprine can be used as an adjunct for short periods (2-3 weeks) 3

  • Start with 5mg three times daily, can increase if needed and tolerated
  • Most effective in the first few days of treatment 4
  • Combination with NSAIDs may provide better relief than NSAIDs alone but causes more drowsiness 5
  • FDA-approved specifically for relief of muscle spasm associated with acute, painful musculoskeletal conditions 3

• Other muscle relaxants (carisoprodol, metaxalone) may be considered 6

  • Low-quality evidence shows no clear differences between different muscle relaxants 2

Considerations for Special Populations

• Elderly patients:

  • Higher risk of medication side effects
  • Use lower doses of muscle relaxants
  • More frequent follow-up recommended 1

• Hepatic impairment:

  • Use cyclobenzaprine with caution in mild impairment, starting with 5mg
  • Not recommended in moderate to severe hepatic impairment 3

Duration of Treatment

• Muscle relaxants should be used only for short periods (2-3 weeks) 3
• Evidence suggests cyclobenzaprine's effect is greatest in the first 4 days of treatment 4
• Longer treatment periods are rarely warranted as muscle spasms associated with acute conditions are generally of short duration 3

Common Pitfalls to Avoid

1. Overreliance on imaging - routine imaging is not recommended for uncomplicated back pain within the first 4-6 weeks 1

2. Prolonged use of muscle relaxants - using beyond 2-3 weeks is not supported by evidence and increases risk of side effects 3

3. Ignoring non-pharmacological approaches - medications should complement, not replace, physical therapy and activity modification 1

4. Starting with opioids - opioids should be avoided as first-line treatment due to risks generally outweighing benefits 1

5. Failing to reassess - if symptoms persist beyond 4-6 weeks or worsen, reevaluation is necessary 1

The evidence supports the existence of a pain-spasm-pain cycle in back disorders 7, which explains why breaking this cycle through appropriate interventions can be effective. While the combination of muscle relaxants with NSAIDs may provide better relief than NSAIDs alone, this comes at the cost of increased side effects, primarily drowsiness 5.