Recommended Treatments for Back Pain

First-Line Treatment: NSAIDs and Activity

Start with NSAIDs (ibuprofen 400 mg every 4-6 hours, maximum 3200 mg daily) combined with advice to remain active and avoid bed rest. 1, 2

NSAIDs provide small to moderate improvements in pain intensity compared to placebo and are the preferred first-line medication for acute low back pain. 1, 2
Acetaminophen can be used as an alternative, particularly in elderly patients or those with cardiovascular/gastrointestinal risk factors, though evidence shows it provides no significant benefit over placebo for pain or function. 2, 3
Patients must remain active and continue ordinary activities within pain limits—bed rest prolongs recovery and worsens outcomes. 1, 2, 4
Apply superficial heat (heating pads or heated blankets) for short-term symptomatic relief. 1, 2, 4

If severe pain persists after 2-4 days despite NSAIDs, add a skeletal muscle relaxant for short-term use (≤1-2 weeks). 5, 2

Cyclobenzaprine has the strongest evidence among muscle relaxants, with moderate-quality evidence showing improved pain relief at 2-7 days compared to placebo. 5, 2
Start with 5 mg doses, particularly in elderly patients or those with hepatic impairment, and titrate slowly upward. 6
All muscle relaxants cause central nervous system adverse effects, primarily sedation—do not prescribe beyond 1-2 weeks as there is no evidence supporting longer duration. 1, 5, 2

For patients not improving with initial treatment after 4 weeks, add non-pharmacologic interventions. 1, 5

For acute low back pain (<4 weeks):

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

Exercise therapy (individualized, supervised programs incorporating stretching and strengthening) has moderate evidence of efficacy. 1
Acupuncture provides moderate benefits with good evidence. 1
Massage therapy shows moderate short-term improvements in pain and function. 1
Cognitive-behavioral therapy has good evidence for moderate efficacy. 1
Yoga (Viniyoga-style) demonstrates fair evidence of effectiveness. 1
Intensive interdisciplinary rehabilitation is moderately effective for subacute and chronic pain. 1

For patients with radicular symptoms (sciatica), consider gabapentin starting at low doses and titrating based on response. 5

If conservative treatment fails for persistent radicular symptoms, epidural steroid injections may be considered. 5

Avoid these interventions as they lack evidence or cause harm:

Systemic corticosteroids—no more effective than placebo for low back pain with or without sciatica. 1, 2, 4
Benzodiazepines—similar effectiveness to muscle relaxants but carry significant risks for abuse, addiction, and tolerance. 1, 2
Antidepressants (except duloxetine for chronic pain) and antiseizure medications for acute low back pain lack sufficient evidence. 2
Prolonged bed rest or activity restriction provides no benefit and delays recovery. 1, 2

Opioids or tramadol should only be considered when severe, disabling pain is not controlled with acetaminophen and NSAIDs. 2

Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction—carefully weigh benefits and harms before initiating. 2
Extended courses of any medication should be reserved for patients showing continued benefits without major adverse events. 1

Do not order imaging initially unless red flags are present (progressive motor/sensory loss, new urinary retention, history of cancer, recent spinal procedure, significant trauma)—imaging does not improve outcomes and may lead to unnecessary interventions. 5
Do not prescribe muscle relaxants beyond 1-2 weeks—no evidence supports longer duration and risks increase. 5, 2
Do not recommend bed rest—it leads to deconditioning and worse outcomes. 5, 2
Monitor for hepatotoxicity when using maximum doses of acetaminophen, especially in elderly or hepatically impaired patients. 2