Initial Treatment for Acute Back Pain
For acute back pain, start with NSAIDs (such as ibuprofen 400mg every 4-6 hours) as first-line medication while strongly advising patients to remain active and avoid bed rest. 1
Immediate Patient Counseling
- Reassure patients that 90% of acute back pain episodes resolve within 6 weeks regardless of treatment 2, 3
- Emphasize staying active and continuing normal daily activities within pain limits—this is more effective than bed rest for recovery 4, 2, 3
- Explicitly advise against bed rest, as it increases disability and worsens outcomes 2, 5
First-Line Pharmacologic Treatment
- NSAIDs are the preferred first-line medication with moderate-quality evidence showing small improvement in pain intensity compared to placebo 1, 4
- Ibuprofen 400mg every 4-6 hours is appropriate; doses above 400mg show no additional benefit for acute pain 6
- Acetaminophen (up to 3000mg daily) is an alternative with a more favorable safety profile, though slightly less effective than NSAIDs 4, 2, 5
- Acetaminophen shows no difference from placebo in low-quality evidence for pain intensity or function through 4 weeks 1
Second-Line Options if Pain Persists
- Skeletal muscle relaxants (SMRs) can be added if NSAIDs alone are insufficient, with moderate-quality evidence showing improved short-term pain relief after 2-7 days 1, 4
- Consider combining SMRs with NSAIDs, though evidence for this combination is inconsistent 1
Non-Pharmacologic Interventions
- Apply superficial heat using heating pads or heated blankets for short-term pain relief 4, 2, 5
- Recommend ice application to painful areas 3
- Advise use of a medium-firm mattress rather than a firm mattress 4, 2
What NOT to Do
- Avoid systemic corticosteroids—low-quality evidence shows no difference in pain or function compared to placebo 1, 4
- Do not order imaging (X-rays, MRI, CT) unless red flags are present or there is no improvement after 6 weeks 1, 2, 5
- Avoid prescribing opioids for acute back pain—evidence is insufficient to determine effectiveness, and risks outweigh benefits 1
- Do not recommend bed rest or activity restriction 2, 3, 7
Red Flags Requiring Immediate Evaluation
- Severe or progressive neurologic deficits (weakness, numbness, loss of bowel/bladder control) 2, 5
- Suspicion of cauda equina syndrome 1, 5, 3
- Concern for malignancy, infection, or spinal fracture 1, 5, 3
When to Reassess
- Reevaluate patients who do not return to normal activity within 4-6 weeks 3, 8
- Consider imaging only after 6 weeks of conservative management without improvement 1, 4, 3
- Most patients experience rapid improvement within the first month, with substantial recovery by 6 weeks 1, 2