What is the treatment for a right low back sprain or strain?

Treatment of Right Low Back Sprain or Strain

For acute low back sprain or strain, initiate treatment with NSAIDs or acetaminophen, advise the patient to remain active rather than rest in bed, and consider adding a skeletal muscle relaxant like cyclobenzaprine for short-term relief if muscle spasm is present. 1, 2, 3

Initial Management (First 4 Weeks)

Pharmacologic Therapy

• NSAIDs are the preferred first-line medication as they provide superior pain relief compared to acetaminophen, though they carry gastrointestinal, renovascular, and cardiovascular risks 2
• Acetaminophen is an acceptable alternative with a more favorable safety profile and lower cost, though it is a slightly weaker analgesic 2
• Add skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain 2, 3
• Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, and should be used only for short periods (up to two or three weeks) 3

Non-Pharmacologic Therapy

• Advise patients to remain active rather than resting in bed, as this approach is more effective for managing back pain 2
• If bed rest is needed for severe symptoms, encourage return to normal activities as soon as possible 2
• Apply superficial heat for short-term relief of acute pain 2
• Provide evidence-based self-care education materials that encourage return to normal activity, adoption of a fitness program, and appropriate lifestyle modification 1, 2

Important Safety Considerations

• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and use the lowest effective dose for the shortest duration 2
• Monitor for asymptomatic aminotransferase elevations with acetaminophen at 4 g/day dosing 2
• Start cyclobenzaprine at 5 mg in patients with mild hepatic impairment and titrate slowly upward; avoid use in moderate to severe hepatic impairment 3

Management for Subacute Pain (4-8 Weeks)

If symptoms persist beyond 4 weeks:

• Initiate intensive interdisciplinary rehabilitation (combining physical therapy, psychological, and vocational interventions coordinated by multiple health care professionals) 1
• Start functional restoration with a cognitive-behavioral component to reduce work absenteeism in occupational settings 1
• Consider spinal manipulation administered by providers with appropriate training, which shows small to moderate short-term benefits 2

Management for Chronic Pain (>3 Months)

If symptoms persist beyond 3 months, implement a multimodal approach:

Evidence-Based Non-Pharmacologic Therapies

• Exercise therapy with individual tailoring, supervision, stretching, and strengthening is moderately effective and associated with the best outcomes 1, 4
• Acupuncture provides moderate effectiveness 1, 4
• Massage therapy is moderately effective 1, 4
• Viniyoga-style yoga is moderately effective 1
• Cognitive-behavioral therapy or progressive relaxation is moderately effective 1, 4
• Spinal manipulation is moderately effective 1, 4
• Intensive interdisciplinary rehabilitation is moderately effective 1, 4

Pharmacologic Options for Chronic Pain

• Continue NSAIDs or acetaminophen as needed 4
• Consider tricyclic antidepressants for pain relief in patients with neuropathic pain components and no contraindications 2
• Consider duloxetine for neuropathic pain component 4

Common Pitfalls to Avoid

• Do not prescribe prolonged bed rest, as it can lead to deconditioning and potentially worsen symptoms 2
• Do not order routine imaging for acute low back sprain without red flags (progressive motor or sensory loss, new urinary retention, history of cancer, recent invasive spinal procedure, or significant trauma) 2, 5
• Avoid transcutaneous electrical nerve stimulation (TENS), as it has not been proven effective for chronic low back pain 1, 4
• Avoid intermittent or continuous traction, as it has not been shown to be effective 1
• Do not use systemic corticosteroids, as they have not been shown to be more effective than placebo 2
• Reserve extended courses of medications for patients clearly showing continued benefits without major adverse events 2

When to Consider Specialist Referral

• Consider consultation with a back specialist when patients do not respond to standard noninvasive therapies 1
• Decisions about consultation should be individualized based on patient symptoms, response to interventions, and availability of specialists with relevant expertise 1
• Immediate intervention is required for cauda equina syndrome (urinary retention or incontinence, bilateral motor weakness, saddle anesthesia) 1, 2