What is the appropriate treatment approach for a patient with back strain who has been undergoing physical therapy (PT) and is now requesting baclofen?

Management of Back Strain: Baclofen Not Recommended as First-Line Treatment

Baclofen is not recommended as first-line treatment for patients with back strain who have been undergoing physical therapy. 1

First-Line Pharmacological Options

• NSAIDs and acetaminophen should be used as first-line medications for back strain due to their favorable efficacy and safety profiles 1, 2

  • NSAIDs are more effective for pain relief than acetaminophen but have greater gastrointestinal and cardiovascular risks 1
  • Clinicians should assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary 1

• Skeletal muscle relaxants other than baclofen are an option for short-term relief of acute back pain 1

  • Tizanidine has been well-studied for low back pain, while there is little evidence for baclofen's efficacy 1
  • All muscle relaxants are associated with central nervous system adverse effects, primarily sedation 1

Evidence Against Baclofen for Back Strain

• There is little evidence supporting baclofen's efficacy for non-spastic back pain 1

  • Although one older study from 1985 showed some benefit of baclofen for acute low back syndrome 3, more recent guidelines do not recommend it as a first-line treatment 1

• Baclofen is primarily indicated for spasticity of spinal origin rather than musculoskeletal back strain 1, 4

  • It is FDA-approved for treatment of spasticity, not for back pain without spasticity 1
  • Baclofen is most effective for rigidity and spasms caused by damage to the spinal cord 4, 5

Recommended Treatment Algorithm for Back Strain

1. Continue physical therapy as a cornerstone of treatment 1, 2

   • Exercise therapy has been shown to be moderately effective for back pain 1
   • Programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes 1

2. First-line medication options:

   • Acetaminophen (up to 4g/day) 1, 2
   • NSAIDs at the lowest effective dose for the shortest duration 1, 2

3. If inadequate relief, consider adding:

   • Skeletal muscle relaxants other than baclofen (e.g., tizanidine) for short-term use 1
   • Avoid benzodiazepines due to risks of abuse, addiction, and tolerance 1

4. For persistent pain:

   • Consider non-pharmacologic therapies with proven benefits: massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation 1
   • For chronic pain (>12 weeks), consider referral for intensive interdisciplinary rehabilitation 1

Special Considerations

• Radiculopathy: If the patient has radicular symptoms, gabapentin may provide small, short-term benefits 1

• Severe, disabling pain: Opioid analgesics or tramadol may be considered when pain is not controlled with acetaminophen and NSAIDs, but risks must be carefully weighed 1

• Monitoring: Assess response to treatment regularly and adjust the approach based on patient response 1, 2

When Baclofen Might Be Considered

• Baclofen should only be considered in cases of documented spasticity that has not responded to other interventions 1, 6, 4

• For severe spastic hypertonia unresponsive to oral medications, intrathecal baclofen may be considered 1, 7, 4

  • Studies show >80% of patients with spasticity have improvement in muscle tone with intrathecal baclofen 4
  • This is not appropriate for typical back strain without spasticity 1, 4