What are the treatment options for a back injury?

Treatment Options for Back Injury

The optimal treatment for back injury includes NSAIDs as first-line pharmacological therapy, heat therapy, and physical therapy with active exercises, while avoiding unnecessary imaging and opioid medications. 1

Initial Assessment and Classification

• Determine if back pain is acute (less than 4 weeks), subacute (4-12 weeks), or chronic (more than 12 weeks)
• Screen for "red flags" suggesting serious pathology:
  • Cauda equina syndrome (urinary retention, saddle anesthesia)
  • Progressive neurological deficits
  • Suspected infection (fever, IV drug use)
  • Suspected fracture (trauma, osteoporosis)
  • Suspected malignancy (history of cancer, unexplained weight loss)

First-Line Treatment (0-2 weeks)

Pharmacological Options

• NSAIDs (first-line): Provide small to moderate pain improvement compared to placebo 1

  • Ibuprofen: Effective analgesic with anti-inflammatory properties 2
  • Limit use to one week when possible to minimize gastrointestinal, renal, and cardiovascular adverse effects 1
  • Caution in patients with asthma, as cross-reactivity with aspirin sensitivity may occur 2

• Muscle Relaxants: Consider adding for acute back pain with muscle spasm 1

  • Improve short-term pain relief after 2-7 days compared to placebo (moderate-quality evidence)
  • Use for short duration only due to sedative effects

• Acetaminophen: May be used for pain control, particularly if NSAIDs are contraindicated 1

Non-Pharmacological Options

• Heat Therapy: Moderately improves pain relief and disability compared to placebo (moderate-quality evidence) 1
• Activity Modification: Encourage continued activity as tolerated rather than bed rest 3
• Patient Education: Provide reassurance about the generally favorable prognosis 3

Second-Line Treatment (if inadequate response after 1-2 weeks)

• Physical Therapy: Focus on active interventions (supervised exercise) rather than passive modalities 1

  • Strongly recommended over no treatment
  • Exercise programs may target general physical fitness, muscle strengthening, or flexibility

• Massage: Moderately improves short-term pain and function for subacute back pain (low-quality evidence) 1

• For Neuropathic Pain Components:

  • Consider duloxetine (30-60mg daily) for chronic back pain with neuropathic features 1
  • Gabapentin or pregabalin may be considered for neuropathic pain 1

Advanced Options for Persistent Pain

• Acupuncture/Acupressure: May provide short-term benefits 4

• Interdisciplinary Rehabilitation: Combines physical, vocational, and behavioral components for complex cases 4

• STarT Back Tool: Can help categorize patients into risk levels for developing persistent pain 1:

  • Low risk: Self-management
  • Medium risk: Physiotherapy with patient-centered plan
  • High risk: Comprehensive biopsychosocial assessment

Surgical Considerations

• Surgery is indicated only for specific conditions 1:

  • Cauda equina syndrome (emergency)
  • Progressive neurological deficits
  • Significant motor deficits
  • Persistent radicular symptoms despite 6-12 weeks of conservative treatment

• Decompression alone is preferred over fusion unless there is instability, spondylolisthesis, or moderate/severe stenosis 1

Common Pitfalls to Avoid

• Unnecessary Imaging: Not recommended for most cases of acute or subacute back pain without red flags 1

  • Imaging can be delayed for at least 4-6 weeks, allowing time for natural improvement 3

• Opioid Prescriptions: Should be avoided or used only as a last resort for very limited duration 1

  • The American College of Physicians and American Academy of Family Physicians suggest against treating acute musculoskeletal pain with opioids 4

• Systemic Corticosteroids: Limited evidence for non-radicular back pain 1

• Premature Surgical Intervention: Current guidelines recommend 4-6 weeks of conservative management before considering surgery 1

• Bed Rest: Restriction of activity merely prolongs recovery and resumption of normal activity 5

Weight Lifters and Back Pain

For athletes and weight lifters with back pain:

• Focus on improved lifting technique and correcting mobility and muscular imbalances 6
• Traditional therapies alone (NSAIDs, general physical therapy) may be insufficient without sport-specific modifications 6

By following this evidence-based approach to back injury management, clinicians can help patients achieve pain relief, functional improvement, and avoid unnecessary treatments that may lead to prolonged disability.