What are the guidelines for managing lower back strain?

Management of Lower Back Strain

Advise patients to remain active and avoid bed rest, provide reassurance about favorable prognosis with substantial improvement expected within the first month, and start with acetaminophen or NSAIDs as first-line medication if needed. 1, 2

Initial Assessment and Triage

Classify the back pain into three categories: 2

• Nonspecific low back pain (most common)
• Pain with radiculopathy or spinal stenosis (leg pain, neurologic symptoms)
• Pain with specific spinal pathology (red flags present)

Do not obtain routine imaging for nonspecific low back pain as it does not improve outcomes and incurs unnecessary expense. 1, 2 Only order MRI or CT when severe/progressive neurologic deficits are present, serious underlying conditions are suspected (red flags), or for persistent symptoms beyond 4 weeks in surgical candidates. 1, 2

Treatment Algorithm by Duration

Acute Low Back Pain (<4 weeks)

Patient Education and Activity (First Priority): 1, 2

• Inform patients of 90% likelihood of substantial improvement within the first month 1, 2
• Advise to remain active - this is more effective than bed rest 1, 2
• If bed rest is needed for severe symptoms, encourage return to normal activities as soon as possible 1
• Provide self-care education materials (such as The Back Book) 1

Pharmacologic Treatment: 1, 2

• First-line: Acetaminophen (up to 3000mg/day) or NSAIDs (e.g., ibuprofen) 1, 2
• Acetaminophen is slightly weaker than NSAIDs but has better safety profile and lower cost 1
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs; use lowest effective dose for shortest duration 1
• Avoid systemic corticosteroids - no greater efficacy than placebo 2

Non-pharmacologic Options: 2, 3

• Heat application (heating pads or heated blankets) provides moderate short-term relief 1, 2, 3
• Spinal manipulation shows small to moderate benefits 2
• Acupuncture may be considered but has limited evidence 2
• Insufficient evidence for cold packs or lumbar supports 1

Muscle Relaxants (if needed): 4

• Cyclobenzaprine 5mg can be added if muscle spasm is prominent, starting with lower dose and titrating slowly 4
• Note increased drowsiness when combined with other therapies 4

Subacute Low Back Pain (4-12 weeks)

Continue effective acute phase treatments and add: 2

• Intensive interdisciplinary rehabilitation with cognitive-behavioral components to reduce work absenteeism 2
• Consider functional restoration programs 2

Chronic Low Back Pain (>12 weeks)

Non-pharmacologic Treatments (Cornerstone of Therapy): 2

• Exercise therapy - moderate efficacy, should be cornerstone of treatment 2
• Cognitive-behavioral therapy - moderate efficacy for pain and function 2
• Spinal manipulation - moderate effectiveness for pain relief and functional improvement 2
• Massage therapy, acupuncture, and yoga - proven benefits 2
• Interdisciplinary rehabilitation combining physical, psychological, and educational interventions 2

Pharmacologic Treatment: 2

• Continue NSAIDs or acetaminophen if effective 2
• Consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors as part of multimodal strategy 2
• Screen and treat coexisting depression appropriately 2
• Consider gabapentin for radicular symptoms 2

Special Considerations for Radiculopathy

For persistent radicular symptoms despite conservative therapy: 1

• Natural history shows improvement within first 4 weeks in most patients with noninvasive management 1
• Consider MRI and specialist referral if symptoms persist beyond 4 weeks 2
• Discectomy or epidural steroids are potential treatment options for prolapsed disc with persistent symptoms 1
• Avoid continuous or intermittent traction - not shown to be effective 2

Common Pitfalls to Avoid

Imaging overuse: 1, 2

• MRI/CT findings (such as bulging disc without nerve root impingement) are often nonspecific and do not correlate with symptoms 1
• Early routine imaging does not improve outcomes 1

Medication misuse: 2

• Avoid overreliance on opioids 2
• Do not prescribe benzodiazepines without time limitations 2
• Systemic corticosteroids lack evidence of efficacy 2

Activity restrictions: 1

• Bed rest worsens disability - passive strategies are associated with worse outcomes 1
• Insufficient evidence exists for specific modified work recommendations, though brief individualized educational interventions can reduce sick leave in workers with subacute pain 1

Work-Related Considerations

For workers with low back pain, consider patient's age, general health, and physical job demands when advising about activity limitations. 1 Brief individualized educational interventions (detailed examination and advice over 1-2 sessions) can reduce sick leave in subacute cases. 1