What is the recommended treatment for back strain?

Treatment of Back Strain

For acute back strain, start with NSAIDs (not acetaminophen) combined with advice to remain active and avoid bed rest, as this provides the most effective initial management. 1, 2

First-Line Treatment

Pharmacologic Management

• NSAIDs are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen for acute back strain 2
• Prescribe NSAIDs at the lowest effective dose for the shortest duration necessary, after assessing cardiovascular and gastrointestinal risk factors 1, 2
• Acetaminophen can be used as an alternative in patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain 2
• When using acetaminophen, limit to maximum 4g/day and monitor for asymptomatic aminotransferase elevations, particularly in elderly patients or those with hepatic impairment 1, 3

Essential Non-Pharmacologic Measures

• Advise patients to remain active and explicitly avoid bed rest, as activity restriction prolongs recovery and delays return to normal activities 1, 2, 4
• Apply superficial heat using heating pads or heated blankets for short-term symptomatic relief 1, 2
• Provide evidence-based self-care education materials to supplement clinical care 3, 4

Second-Line Treatment (If Initial Treatment Inadequate)

Additional Pharmacologic Options

• Add skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain 3, 2
• All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation, so prescribe time-limited courses only 2, 5
• Cyclobenzaprine should be used with caution in patients with mild hepatic impairment, starting with 5mg dose and titrating slowly; avoid in moderate to severe hepatic impairment 5
• Cyclobenzaprine is indicated only for short periods (up to 2-3 weeks) as an adjunct to rest and physical therapy 5

Non-Pharmacologic Therapies

• Consider spinal manipulation by appropriately trained providers, which shows small to moderate short-term benefits for acute pain 3, 2, 4
• For chronic or subacute back strain, expand options to include exercise therapy, massage therapy, acupuncture, and cognitive-behavioral therapy 1, 3

Third-Line Treatment (For Severe, Refractory Pain)

• Reserve opioid analgesics or tramadol only for severe, disabling pain uncontrolled by NSAIDs and acetaminophen 1, 2
• Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction; carefully weigh benefits and harms before initiating therapy 1, 2
• Use judiciously with time-limited prescriptions and clear expectations 1

Critical Pitfalls to Avoid

• Do not prescribe bed rest or recommend activity restriction, as this provides no benefit and delays recovery 1, 2, 4
• Do not use systemic corticosteroids for back strain, as they have not been shown more effective than placebo 3, 2
• Avoid benzodiazepines despite similar effectiveness to muscle relaxants, due to risks for abuse, addiction, and tolerance 2
• Do not prescribe extended courses of medications without clear evidence of continued benefits and absence of major adverse events 1, 4
• Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute back strain 2

When to Escalate Care

• Consider imaging (MRI preferred over CT) only if symptoms persist beyond 4-6 weeks and patient is a potential candidate for surgery or epidural steroid injection 4
• Immediately evaluate for red flags including cauda equina syndrome (medical emergency requiring immediate intervention), progressive neurological deficits, suspected infection, or malignancy 3, 4
• Most patients improve within 4-6 weeks regardless of treatment, though up to one-third may have persistent moderate pain at one year 4