What is the initial treatment for acute upper back pain?

Initial Treatment for Acute Upper Back Pain

For acute upper back pain, the first-line treatment should include remaining active within pain limits, application of heat, and NSAIDs or acetaminophen as needed for pain relief. 1, 2

Non-Pharmacological Management

• Provide reassurance about the favorable prognosis, as most episodes of acute back pain resolve within 4-6 weeks regardless of treatment 2, 3
• Advise patients to remain active and continue ordinary activities within the limits permitted by pain, avoiding bed rest 1, 2
• Application of heat via heating pads or heated blankets is recommended for short-term relief of acute back pain 1, 4, 5
• Medium-firm mattresses are preferable to firm mattresses for back pain relief 1, 4
• Consider referral for spinal manipulation which demonstrates moderate benefits for acute back pain 2, 5

Pharmacological Management

• NSAIDs (such as ibuprofen) are recommended as first-line medication with moderate-quality evidence showing small improvement in pain intensity compared to placebo 1, 6

  • Use the lowest effective dose for the shortest duration (typically 400mg every 4-6 hours as needed) 6, 3
  • Assess cardiovascular and gastrointestinal risk factors before prescribing 1, 4

• Acetaminophen is an alternative first-line option with a more favorable safety profile, though it may provide slightly less pain relief than NSAIDs 1, 4

  • Recommended dosage is up to 4g/day from all sources 4

• Skeletal muscle relaxants (SMRs) can be considered if pain persists, with moderate-quality evidence showing improved short-term pain relief after 2-7 days compared to placebo 1, 7

  • For cyclobenzaprine, start with 5mg and titrate slowly upward, using caution in patients with hepatic impairment 7

Treatment Algorithm

1. First 1-2 days:

   • Begin with heat application and activity modification (staying active within pain limits) 1, 2
   • Start NSAIDs (e.g., ibuprofen 400mg every 4-6 hours as needed) or acetaminophen (up to 4g/day) 1, 6

2. If inadequate relief after 2-3 days:

   • Consider adding a skeletal muscle relaxant 1, 7
   • Maintain heat therapy and appropriate activity levels 1, 2

3. If no improvement after 1-2 weeks:

   • Consider referral for goal-directed manual physical therapy 3
   • Reassess for any red flags that might warrant further investigation 2, 3

Special Considerations

• For elderly patients, acetaminophen may be preferred over NSAIDs due to lower risk of adverse effects 4
• Systemic corticosteroids are not recommended as low-quality evidence shows no difference in pain or function compared with placebo 1, 2
• Opioids should be reserved for severe, disabling pain not controlled with acetaminophen and NSAIDs, and only after carefully weighing potential benefits and harms 1, 4
• Diagnostic imaging is not recommended unless there is suspicion of serious underlying pathology or no improvement after 6 weeks 2, 3

Common Pitfalls to Avoid

• Recommending bed rest, which can delay recovery 1, 3
• Overuse of imaging for acute back pain without red flags 2, 3
• Prescribing opioids as first-line treatment 1, 4
• Neglecting non-pharmacological approaches like heat therapy and maintaining activity 1, 2
• Continuing with ineffective treatments beyond 2 weeks without reassessment or modification 2, 3