What is the initial management for muscular skeletal back pain?

Initial Management of Musculoskeletal Back Pain

Start with education, reassurance, and NSAIDs while keeping the patient active—avoid bed rest, acetaminophen monotherapy, and opioids. 1

Immediate Assessment

• Screen for red flags (cancer, infection, fracture, cauda equina syndrome, progressive neurologic deficits) that require urgent imaging or specialist referral 1, 2
• Assess psychosocial factors (depression, anxiety, fear-avoidance beliefs, work dissatisfaction) as these predict chronicity and disability 1
• Perform physical examination to differentiate nonradicular from radicular pain, though routine imaging is not indicated initially 1, 2

First-Line Non-Pharmacologic Management

• Provide education and reassurance that 90% of acute episodes resolve within 6 weeks regardless of treatment 2, 3
• Advise patients to stay active and continue ordinary activities within pain limits—bed rest worsens outcomes 1, 2
• Recommend early return to work as this reduces long-term disability 1
• Consider exercise therapy as a cornerstone intervention, including McKenzie exercises for pain radiating below the knee 1, 2
• Apply heat or ice to painful areas for symptomatic relief 2

First-Line Pharmacologic Management

• NSAIDs are the preferred first-line medication with moderate evidence for pain relief (effect size 0.5-0.8,10-20 point improvement on 100-point scale) 1, 4, 5
• Acetaminophen should NOT be used as monotherapy as recent evidence shows it is ineffective for acute low back pain 1
• Limit NSAID duration as most trials were only 2 weeks; evidence beyond 6 weeks is sparse 5

When to Add Muscle Relaxants

• Add a skeletal muscle relaxant if NSAIDs provide inadequate relief or if muscle spasm is prominent 4
• Tizanidine is the preferred muscle relaxant (start 2-4 mg, titrate as needed), particularly for radicular symptoms 4
• Cyclobenzaprine is FDA-approved as an adjunct to rest and physical therapy for acute, painful musculoskeletal conditions 6
• Limit muscle relaxant use to 1-2 weeks due to lack of long-term efficacy data and sedation risk 1, 4, 6
• Warn patients about sedation as all skeletal muscle relaxants cause central nervous system adverse effects 1, 4
• Monitor for hepatotoxicity with tizanidine though this is generally reversible 4

What NOT to Do

• Do not prescribe opioids for chronic low back pain as evidence shows no benefit over NSAIDs and substantial harm potential 1
• Do not prescribe benzodiazepines as they are ineffective for radiculopathy and nonradicular pain 1
• Do not prescribe antidepressants (SSRIs, SNRIs, tricyclics) or anticonvulsants for routine low back pain 1
• Do not order routine imaging unless red flags are present, neurologic deficits exist, or pain persists beyond 6 weeks 1, 2, 3
• Do not refer for passive modalities (heat, traction, ultrasound, TENS) as evidence is limited 1, 2
• Do not offer spinal injections (facet joint, trigger point, prolotherapy) for nonspecific low back pain 1

Special Consideration for Radicular Pain

• For radiculopathy (leg pain/sciatica), combine tizanidine with gabapentin as adjunctive therapy for small, short-term benefits 4
• NSAIDs show no benefit for predominantly radicular symptoms making them a poor choice when leg pain dominates 5

When to Escalate Care

• Refer for goal-directed manual physical therapy if no improvement in 1-2 weeks 2
• Consider imaging after 6 weeks of persistent symptoms without improvement 2, 3
• Refer to specialist if functional disability persists despite conservative management or if red flags emerge 3, 7

Common Pitfalls to Avoid

The most critical error is prescribing opioids early—recent research shows no additional benefit over NSAIDs for acute low back pain while carrying substantial addiction and overdose risk 1. Another major pitfall is ordering premature imaging, which increases costs without improving outcomes and may lead to unnecessary interventions 1. Finally, advising bed rest is counterproductive and increases disability 1, 2.