What are the steps for managing lumbar (low back) pain?

From the Guidelines

For low back pain, the first step is to provide patients with evidence-based information on low back pain, advise them to remain active, and provide information about effective self-care options. This approach is based on the strong recommendation and moderate-quality evidence from the American College of Physicians and the American Pain Society 1. The guidelines suggest that clinicians should inform patients about the generally favorable prognosis of acute low back pain, including a high likelihood for substantial improvement in the first month.

Some key self-care measures for low back pain include:

• Remaining active, as this is more effective than resting in bed for patients with acute or subacute low back pain 1
• Applying heat or cold packs for short-term relief of acute low back pain 1
• Using a medium-firm mattress, as firm mattresses are less likely to lead to improvement in patients with chronic low back pain 1
• Considering physical therapy for persistent pain, as it can help relieve pain and improve function

In terms of medication, acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line options for patients with low back pain, due to their moderate, primarily short-term benefits and relatively favorable safety profiles 1. However, clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.

It's also important to note that if pain is severe, radiates down the leg, is accompanied by numbness/tingling, or doesn't improve within 2-3 weeks, patients should seek medical attention, as these could indicate more serious conditions requiring different treatment approaches. Additionally, clinicians should consider the use of nonpharmacologic therapy with proven benefits, such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation, for patients who do not improve with self-care options 1.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions The step for low back pain is to use cyclobenzaprine hydrochloride tablets as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, such as low back pain 2.

• The recommended treatment duration is up to two or three weeks.
• Cyclobenzaprine should be used with caution in patients with mild hepatic impairment, starting with a 5 mg dose and titrating slowly upward 2.

From the Research

Steps for Low Back Pain

• Identify red flags that may indicate serious conditions, such as recent trauma, fever, or unexplained weight loss 3
• Perform a physical examination to evaluate for radicular symptoms and neuromuscular deficits 3, 4
• Use routine imaging only when red flags are present, or if pain does not resolve with conservative therapy 3, 4
• Avoid bed rest and recommend nonpharmacologic treatment, such as:
  • Counseling 3
  • Exercise therapy 3, 4, 5
  • Spinal manipulation 3, 4
  • Massage 3, 4
  • Heat 3
  • Dry needling 3
  • Acupuncture 3, 4
  • Transcutaneous electrical nerve stimulation 3
  • Physical therapy 3
• Consider pharmacologic interventions, such as:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) as the initial medication of choice 3, 4
  • Duloxetine for patients who do not respond to NSAIDs 3
• Refer patients to specialty care if they have a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis 5
• Educate patients about the natural history of low back pain and how to prevent future episodes 5