What is the recommended treatment protocol for back pain?

Treatment Protocol for Back Pain

Start with NSAIDs (ibuprofen 400mg every 4-6 hours, maximum 3200mg daily) combined with advice to remain active and avoid bed rest, as this provides the most effective initial management for back pain. 1, 2, 3

Initial Assessment and Red Flag Screening

Before initiating treatment, rapidly screen for serious conditions requiring urgent intervention:

• Check for cauda equina syndrome (new urinary retention, overflow incontinence, saddle anesthesia) requiring immediate surgical referral 2, 4
• Assess for progressive neurologic deficits (motor weakness, sensory loss) warranting urgent imaging 1, 2
• Screen for infection or malignancy (fever, unexplained weight loss, history of cancer, immunosuppression) 2, 4
• Evaluate fracture risk (significant trauma relative to age, osteoporosis, prolonged corticosteroid use) 2, 4

Do not obtain routine imaging for nonspecific low back pain without red flags, as findings are often nonspecific and do not improve outcomes. 1, 4

First-Line Treatment (Start Immediately)

Pharmacologic Management

NSAIDs are superior to acetaminophen and should be the preferred first-line medication:

• Prescribe ibuprofen 400mg every 4-6 hours (maximum 3200mg daily), or equivalent NSAID at lowest effective dose for shortest duration 1, 3, 5
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 3
• Acetaminophen (up to 3000-4000mg daily) is an acceptable alternative only for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain 2, 3, 4
• Monitor for hepatotoxicity with acetaminophen, especially in elderly or those with liver disease 2, 3

Non-Pharmacologic Management

These interventions are equally important as medications:

• Advise patients to remain active and explicitly avoid bed rest, as activity restriction prolongs recovery and delays return to normal function 1, 2, 3, 4
• Apply superficial heat via heating pads or heated blankets for short-term symptomatic relief 3, 4
• Provide evidence-based reassurance about favorable prognosis, with most patients improving within 4-6 weeks regardless of treatment 2, 4

Second-Line Treatment (If No Improvement After 1-2 Weeks)

Additional Pharmacologic Options

Add these medications only if NSAIDs alone are insufficient:

• Skeletal muscle relaxants (e.g., cyclobenzaprine, methocarbamol) for short-term relief when muscle spasm contributes to pain, but prescribe time-limited courses only due to sedation risk 1, 2, 3
• Avoid benzodiazepines despite similar effectiveness to muscle relaxants, given risks for abuse, addiction, and tolerance 3, 4

Non-Pharmacologic Therapies

For acute low back pain (< 4 weeks):

• Spinal manipulation by appropriately trained providers (chiropractors, osteopaths, physical therapists) shows small to moderate short-term benefits 1, 2, 3, 4

For chronic or subacute low back pain (≥ 4 weeks):

• Exercise therapy is a cornerstone of treatment with moderate efficacy 1, 4, 6
• Cognitive-behavioral therapy demonstrates moderate efficacy for chronic pain 1, 4
• Acupuncture, massage therapy, and yoga show small to moderate benefits 1, 4
• Intensive interdisciplinary rehabilitation combining physical, psychological, and educational interventions is effective for chronic pain 1, 4

Third-Line Treatment (For Severe, Refractory Pain)

When to Consider Advanced Options

Reserve these interventions for patients who fail first and second-line treatments:

• Opioid analgesics or tramadol may be considered only when severe, disabling pain is not controlled with NSAIDs, given substantial risks of abuse, addiction, and aberrant drug-related behaviors 1, 3
• Tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) as part of multimodal strategy for chronic back pain 1, 4
• Gabapentin for radicular symptoms 4

Advanced Imaging and Interventions

Obtain MRI only under specific circumstances:

• Patient is a potential candidate for surgery or epidural steroid injection AND symptoms persist beyond 4-6 weeks despite conservative management 1, 2, 4
• Prefer MRI over CT for superior soft-tissue contrast without radiation exposure 2
• Epidural steroid injections may benefit patients with radicular symptoms, though studies show mixed results 7

Critical Pitfalls to Avoid

• Never prescribe bed rest or activity restriction – this provides no benefit and delays recovery 2, 3, 4
• Do not use systemic corticosteroids for acute low back pain with or without sciatica, as they are not more effective than placebo 3, 4
• Avoid extended medication courses without clear evidence of continued benefits and absence of major adverse events 2, 3
• Do not overuse imaging – findings on MRI or CT are often nonspecific and do not improve outcomes 4
• Screen and treat comorbid depression, which commonly coexists with chronic back pain 4

Treatment Algorithm by Duration

Acute (< 4 weeks): NSAIDs + remain active + superficial heat → Add muscle relaxants or spinal manipulation if needed 1, 2, 3

Subacute (4-12 weeks): Continue effective acute treatments → Add exercise therapy, cognitive-behavioral therapy, or intensive interdisciplinary rehabilitation 1, 4

Chronic (> 12 weeks): NSAIDs or acetaminophen if effective → Add tricyclic antidepressants or SNRIs → Expand to exercise therapy, cognitive-behavioral therapy, spinal manipulation, massage, acupuncture, yoga 1, 4

Most patients improve within 4-6 weeks regardless of treatment, though up to one-third may have persistent moderate pain at one year. 2