What is the recommended treatment for back strain?

Treatment for Back Strain

For back strain, advise patients to remain active and avoid bed rest, start NSAIDs as first-line medication, and apply superficial heat for short-term relief. 1, 2, 3

First-Line Treatment Approach

Activity Modification

• Patients must remain active and continue ordinary activities within pain limits rather than resting in bed, as bed rest prolongs recovery and increases disability. 1, 2, 3
• Reassure patients that 90% of acute back strain episodes resolve within 6 weeks regardless of treatment, though minor flare-ups may occur in the subsequent year. 4
• Provide evidence-based self-care education materials (such as The Back Book) that reinforce staying active and returning to normal activities. 1

Pharmacologic Management

• NSAIDs are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen, and should be prescribed at the lowest effective dose for the shortest duration. 2, 3
• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs, as they carry renovascular and cardiovascular risks. 2
• Acetaminophen (up to 4g/day) is an acceptable alternative for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain. 2, 3
• Monitor for hepatotoxicity when using maximum acetaminophen doses, especially in elderly patients or those with hepatic impairment. 3

Self-Care Options

• Application of superficial heat via heating pads or heated blankets provides short-term symptomatic relief for acute back strain. 1, 2, 3
• Heat and cold packs produce similar mild improvements in pain when combined with NSAIDs, so choice should be based on patient preference. 5

Second-Line Treatment for Persistent Symptoms

Muscle Relaxants

• Consider skeletal muscle relaxants (cyclobenzaprine, tizanidine, or metaxalone) for short-term relief when muscle spasm contributes to pain, as they improve pain relief after 2-7 days compared to placebo. 2, 3
• All muscle relaxants cause central nervous system adverse effects, primarily sedation, and should only be prescribed for time-limited courses (2-3 weeks maximum). 3, 6
• Cyclobenzaprine should be used with caution in patients with hepatic impairment, starting with 5mg and titrating slowly upward. 6

Manual Therapy

• Spinal manipulation by appropriately trained providers provides small to moderate short-term benefits for acute back strain when initial treatment fails. 2, 3
• Refer for goal-directed manual physical therapy if no improvement occurs in 1-2 weeks, avoiding passive modalities like ultrasound or TENS. 4

Treatments NOT Recommended

• Do not prescribe systemic corticosteroids, as they are not more effective than placebo for acute low back pain. 3
• Avoid benzodiazepines despite similar effectiveness to muscle relaxants, due to risks for abuse, addiction, and tolerance. 3
• Do not recommend bed rest or activity restriction, as this provides no benefit and delays recovery. 3
• Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute back strain. 3

When to Escalate Care

Opioid Considerations

• Reserve opioid analgesics or tramadol only for severe, disabling pain uncontrolled by NSAIDs, given substantial risks of abuse, addiction, and aberrant drug-related behaviors. 3

Imaging Indications

• Do not obtain routine imaging unless symptoms persist beyond 6 weeks without improvement, red flags develop (cauda equina syndrome, progressive neurological deficits, infection, malignancy, fracture), or the patient becomes a candidate for invasive interventions. 2, 7, 4

Referral Considerations

• Consider consultation with a back specialist when patients do not respond to standard noninvasive therapies after 4-6 weeks, though most patients improve within this timeframe. 1

Critical Pitfalls to Avoid

• Never prescribe extended medication courses without clear ongoing benefit and absence of major adverse events. 2, 3
• Do not order imaging in the absence of red flags, as this leads to unnecessary interventions without improving outcomes and increases healthcare costs. 7
• Avoid recommending prolonged bed rest, as this causes deconditioning and worsens disability. 1, 2, 3