What should I do for lower back pain that persists after waking up for three weeks?

Management of Persistent Lower Back Pain After Three Weeks

For lower back pain persisting after waking up for three weeks, you should initially select nonpharmacologic treatments including exercise therapy, physical therapy, or heat application, before considering NSAIDs as first-line pharmacologic therapy. 1

Classification and Initial Assessment

Your back pain falls into the subacute category (4-12 weeks) based on the American College of Physicians guidelines 1. Key considerations include:

• Rule out red flags: Severe neurological deficits, cauda equina syndrome, or progressive neurological deterioration require immediate specialist evaluation 2
• Assess for radicular symptoms: Pain radiating down the leg below the knee suggests nerve root involvement 1
• Morning stiffness pattern: Pain that worsens upon waking suggests possible inflammatory component

Treatment Algorithm

Step 1: Nonpharmacologic Approaches (First-Line)

• Exercise therapy: Shown to improve function and prevent worsening disability 3
• Heat application: Good evidence for effectiveness in subacute back pain 4
• Physical therapy: Focus on core strengthening and proper body mechanics 3
• Avoid bed rest: Active strategies decrease disability while passive methods worsen it 3

Step 2: Pharmacologic Approaches (If needed)

1. NSAIDs (First-line pharmacologic option): Moderate-quality evidence supports their use 1
2. Muscle relaxants (Alternative first-line): Consider cyclobenzaprine for short-term use (up to 2-3 weeks) if muscle spasm is present 5
3. Second-line options: If inadequate response to above, consider tramadol or duloxetine 1

Important Considerations

• Timing of imaging: Routine imaging is not recommended for nonspecific back pain until at least 4-6 weeks of conservative treatment 4, 6
• Duration of treatment: Muscle relaxants like cyclobenzaprine should only be used for short periods (2-3 weeks) as evidence for longer use is lacking 5
• Avoid opioids: Only consider if all other treatments have failed and after discussing risks and benefits 1

When to Consider Specialist Referral

Consider referral to a back specialist if pain persists despite standard noninvasive therapies after 3 months 1, 6, particularly if:

• Pain significantly limits daily activities
• Symptoms worsen despite appropriate treatment
• Neurological symptoms develop

Common Pitfalls to Avoid

• Overreliance on passive treatments: Focus on active strategies like exercise rather than solely relying on medications 3
• Premature imaging: Unnecessary imaging can lead to incidental findings and potentially unnecessary interventions 4
• Extended use of muscle relaxants: Cyclobenzaprine should only be used short-term as effectiveness for prolonged use is not established 5
• Bed rest: This can worsen outcomes and prolong recovery 3

By following this structured approach, most cases of subacute back pain will improve. The key is to stay active, use appropriate nonpharmacologic treatments first, and add medications judiciously if needed.