What is best said for acute lower back pain?

From the Guidelines

For acute lower back pain, the best approach is to stay active and consider nonpharmacologic treatments such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation as first-line therapy. According to the American College of Physicians guideline 1, these treatments have moderate to low-quality evidence supporting their use. The guideline strongly recommends these nonpharmacologic treatments for acute, subacute, and chronic low back pain.

Some key points to consider when managing acute lower back pain include:

• Staying active and maintaining normal activities as tolerated, rather than strict bed rest, which can delay recovery
• Considering nonpharmacologic treatments as first-line therapy, such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation
• Using over-the-counter pain medications, such as acetaminophen or ibuprofen, as needed for pain management
• Applying heat or ice to the painful area for 15-20 minutes several times daily to reduce pain and inflammation
• Gentle stretching and walking to maintain mobility and reduce stiffness

It's essential to note that most acute back pain resolves within 4-6 weeks without specific treatment, and these recommendations prioritize maintaining movement, reducing pain and inflammation, and promoting conservative management. If pain is severe, persists beyond 6 weeks, includes leg weakness/numbness, or affects bladder/bowel function, seeking medical attention promptly is crucial. The American College of Physicians guideline 1 provides a comprehensive framework for managing acute, subacute, and chronic low back pain, emphasizing the importance of nonpharmacologic treatments and careful consideration of pharmacologic options.

From the FDA Drug Label

Clinical Studies Eight double-blind controlled clinical studies were performed in 642 patients comparing cyclobenzaprine hydrochloride 10 mg, diazepam, and placebo. Muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living were evaluated The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. One study compared cyclobenzaprine hydrochloride tablets 5 and 10 mg t.i. d. to placebo; and a second study compared cyclobenzaprine hydrochloride tablets 5 and 2.5 mg t.i. d. to placebo. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

Cyclobenzaprine is effective for acute lower back pain. The recommended dose is 5 mg t.i.d. 2

• Key benefits:
  • Relief from starting backache
  • Global impression of change
  • Medication helpfulness
  • Reduction in palpable muscle spasm
• Key points:
  • Cyclobenzaprine produces clinical improvement whether or not sedation occurs
  • The overall effectiveness of cyclobenzaprine was similar to that observed in the double-blind controlled studies

From the Research

Recommendations for Acute Lower Back Pain

• Advise patients to stay active and continue ordinary activity within the limits permitted by pain, avoid bed rest, and return to work early, which is associated with less disability 3
• Consider McKenzie exercises, which are helpful for pain radiating below the knee 3
• Recommend acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) if medication is necessary 3, 4, 5, 6, 7
• COX-2 inhibitors, muscle relaxants, and opiate analgesics have not been shown to be more effective than NSAIDs for acute low back pain 3
• Consider imaging if patients have no improvement after 6 weeks, although diagnostic tests or imaging is not usually required 3, 6, 7

Pharmacologic Management

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain 4
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries 4
• Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 4
• Muscle relaxants may be useful for acute low back pain 4, 5, 6

Non-Pharmacologic Management

• Reassure patients that 90% of episodes resolve within 6 weeks-regardless of treatment 3
• Advise patients that minor flares-ups may occur in the subsequent year 3
• Recommend ice for painful areas and stretching exercises 3
• Discuss the use of proper body mechanics and safe back exercises for injury prevention 3
• Refer for goal-directed manual physical therapy if there is no improvement in 1 to 2 weeks 3