What are the best treatments for acute lower back pain?

Treatment of Acute Lower Back Pain

For acute lower back pain, start with reassurance about the excellent prognosis, advise patients to remain active and avoid bed rest, and use NSAIDs or acetaminophen as first-line medications, reserving skeletal muscle relaxants for patients who fail initial therapy. 1, 2

Initial Management Approach

Patient Education and Activity Modification

• Reassure patients that approximately 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment, with pain and disability typically improving rapidly in the first month 1, 3
• Advise patients to remain active and continue ordinary activities within the limits permitted by pain rather than prescribing bed rest, which prolongs recovery 1, 2, 3
• Provide evidence-based self-care information and encourage early return to work, which is associated with less long-term disability 1, 2

Diagnostic Imaging: When NOT to Order

• Do not routinely obtain imaging or diagnostic tests for nonspecific acute low back pain, as this does not improve outcomes and findings are often nonspecific 1, 2
• Reserve imaging only for patients with "red flags" suggesting serious underlying conditions (fracture, infection, tumor, cauda equina syndrome) or severe/progressive neurologic deficits 1, 2
• If no improvement occurs after 6 weeks of conservative management, then consider imaging 3

Pharmacologic Treatment Algorithm

First-Line Medications

• NSAIDs (such as ibuprofen) are the preferred first-line option, with moderate-quality evidence showing small improvement in pain intensity compared to placebo 1, 4
• Acetaminophen (up to 3000mg/day) is an alternative first-line option with a more favorable safety profile, though low-quality evidence shows it may be no more effective than placebo 1, 2, 4
• For elderly patients, acetaminophen may be preferred over NSAIDs due to lower risk of gastrointestinal and cardiovascular adverse effects 4

Second-Line Medications (If First-Line Fails)

• Skeletal muscle relaxants (SMRs) such as cyclobenzaprine can be added if pain persists after 2-4 days, with moderate-quality evidence showing improved short-term pain relief after 2-7 days 1, 4
• Prescribe SMRs for fixed, limited periods due to sedation and drowsiness as common side effects 1, 5
• The combination of SMRs plus NSAIDs shows inconsistent evidence for additional benefit over NSAIDs alone 1

Medications to AVOID

• Do not use systemic corticosteroids (oral or intramuscular), as low-quality evidence shows no difference in pain or function compared to placebo 1, 2, 4
• Reserve opioids only for severe, disabling pain not controlled with acetaminophen and NSAIDs, and only after carefully weighing potential benefits against substantial harms including abuse potential 4, 6
• Insufficient evidence exists for benzodiazepines, antidepressants, and antiseizure medications in acute low back pain 1

Nonpharmacologic Treatment Options

Effective Interventions

• Superficial heat application (heating pads or heated blankets) shows good evidence for moderate short-term pain relief in acute low back pain 1, 2, 4
• Spinal manipulation demonstrates fair evidence for small to moderate benefits and can be considered for patients not improving with self-care 1, 2
• Ice application to painful areas may provide symptomatic relief 3

Interventions with Limited or No Benefit

• Traction shows no evidence of effectiveness compared to placebo or sham treatment 1, 2
• TENS (transcutaneous electrical nerve stimulation) lacks evidence of benefit 1
• Bed rest is contraindicated and prolongs recovery 1, 2, 7

Common Pitfalls to Avoid

Overuse of Imaging

• Avoid ordering MRI or CT for nonspecific acute low back pain, as degenerative findings are common in asymptomatic individuals and do not guide treatment 1, 2
• A negative plain film does not rule out serious disease if clinical suspicion remains high 3

Medication Misuse

• Avoid prescribing opioids as first-line therapy due to abuse potential and lack of evidence for superior efficacy over NSAIDs 1, 6
• Do not prescribe benzodiazepines or muscle relaxants without time limitations, as prolonged use increases risk of dependence 2
• Avoid systemic corticosteroids entirely, as they lack efficacy evidence 1, 2

Activity Restriction

• Do not prescribe bed rest or prolonged activity restriction, which delays recovery and return to normal function 1, 2, 7
• Exercise therapy for acute pain is no more effective than continuation of normal daily activities 7

When to Reassess or Refer

• If symptoms persist beyond 1-2 weeks without improvement, consider adding nonpharmacologic therapies such as spinal manipulation or goal-directed manual physical therapy 1, 3
• Reassess at 4-6 weeks; if no improvement occurs, consider imaging and specialist referral 2, 3
• Screen for psychosocial risk factors (depression, job dissatisfaction, catastrophizing) that predict chronic disabling back pain 1, 2