What is the recommended treatment for acute low back strain?

Treatment for Acute Low Back Strain

For acute low back strain, first-line treatment should include nonpharmacologic approaches such as superficial heat application, remaining active, and avoiding bed rest, along with pharmacologic options of NSAIDs or skeletal muscle relaxants if medication is desired. 1, 2

Initial Management Approach

• Provide reassurance about the favorable prognosis, as most acute low back pain improves within the first month regardless of treatment 1, 2
• Advise patients to remain active and avoid bed rest, as continuing ordinary activities within pain limits leads to more rapid recovery 2, 3
• Apply superficial heat via heating pads or heated blankets for short-term relief 1, 2
• Consider massage, acupuncture, or spinal manipulation as nonpharmacologic options with evidence of benefit 1, 2

Pharmacologic Options

First-Line Medications

• NSAIDs (such as ibuprofen) are effective for pain relief with moderate benefit for acute low back pain 1
• Acetaminophen (up to 3000mg/day) is a reasonable first option, especially in elderly patients due to its favorable safety profile 2, 4
• Skeletal muscle relaxants show moderate effectiveness for acute low back pain and can be considered if NSAIDs are insufficient 1

Muscle Relaxants Considerations

• Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 5
• Use muscle relaxants only for short periods (up to 2-3 weeks) as evidence for longer use is inadequate 5
• Start with lower doses (5mg) in elderly patients or those with mild hepatic impairment 5
• Be aware that drowsiness is a common side effect of muscle relaxants 5

What to Avoid

• Avoid systemic corticosteroids as they have not shown greater efficacy than placebo for low back pain 1, 2
• Avoid bed rest as it prolongs recovery and resumption of normal activity 2, 3
• Avoid routine imaging (X-ray, MRI, CT) for nonspecific low back pain without red flags 2
• Avoid opioids as first-line therapy due to risk of dependence and side effects 1, 2

Special Considerations

• For patients with radiculopathy (nerve root impingement), gabapentin may provide small, short-term benefits 1
• Screen for and treat depression appropriately as it commonly coexists with back pain 1, 2
• Consider referral to a specialist if symptoms persist beyond 4 weeks despite conservative management 2

Red Flags Requiring Further Evaluation

• History of trauma, fever, incontinence, unexplained weight loss, cancer history, long-term steroid use, parenteral drug abuse, or intense localized pain with inability to find comfortable position 6
• Progressive neurological deficits require prompt evaluation 2

Treatment Duration

• Most acute low back pain episodes are self-limited and resolve within 4 weeks 1, 7
• If pain persists beyond 4 weeks (becoming subacute), consider adding more intensive approaches such as structured exercise programs or multidisciplinary rehabilitation 1, 2