What are the treatment guidelines for lower back pain (lumbago)?

From the Guidelines

Clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options. When treating lumbago, it is essential to consider the patient's overall well-being and quality of life. According to the American College of Physicians and the American Pain Society's joint clinical practice guideline 1, the primary goal is to manage pain and improve functional deficits.

Key Recommendations

• Provide patients with evidence-based information on low back pain, including expected course and self-care options 1
• Advise patients to remain active, as this can help improve outcomes and reduce pain 1
• Consider the use of medications with proven benefits, such as acetaminophen or nonsteroidal anti-inflammatory drugs, in conjunction with back care information and self-care 1
• For patients who do not improve with self-care options, consider the addition of nonpharmacologic therapy with proven benefits, such as spinal manipulation, exercise therapy, or cognitive-behavioral therapy 1

Treatment Approach

Treatment of lumbago typically begins with conservative measures, including:

• Providing evidence-based information on low back pain and advising patients to remain active 1
• Using medications with proven benefits, such as acetaminophen or nonsteroidal anti-inflammatory drugs, to manage pain and inflammation 1
• Considering nonpharmacologic therapy with proven benefits, such as spinal manipulation or exercise therapy, for patients who do not improve with self-care options 1 It is crucial to 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 1. By prioritizing patient education, self-care, and evidence-based treatment options, clinicians can help improve outcomes and reduce morbidity, mortality, and improve quality of life for patients with lumbago.

From the FDA Drug Label

The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. One study compared cyclobenzaprine hydrochloride tablets 5 and 10 mg t.i.d. to placebo; and a second study compared cyclobenzaprine hydrochloride tablets 5 and 2.5 mg t.i.d. to placebo. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache. Analysis of the data from controlled studies shows that cyclobenzaprine produces clinical improvement whether or not sedation occurs.

The treatment guidelines for lumbago (lower back pain) using cyclobenzaprine include:

• Starting with a dose of 5 mg and titrating slowly upward
• Using cyclobenzaprine hydrochloride tablets 3 times a day
• The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients 2
• Cyclobenzaprine produces clinical improvement whether or not sedation occurs 2 Key points to consider:
• Dose: Start with 5 mg and titrate slowly upward
• Administration: 3 times a day
• Efficacy: Demonstrated in clinical trials with 1405 patients
• Side effects: May include drowsiness, dry mouth, and dizziness 2 2

From the Research

Treatment Guidelines for Lumbago

• The treatment of lumbago, also known as chronic low back pain, typically involves a combination of non-pharmacologic and pharmacologic interventions 3.
• Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 3.
• Pharmacologic interventions are second-line treatment, with nonsteroidal anti-inflammatory drugs being the initial medication of choice; duloxetine may also be beneficial 3.
• For patients with discogenic low back pain, treatment modalities include noninvasive treatments such as drug therapy, multiple physical modalities, and multidisciplinary biopsychosocial rehabilitation; interventional modalities such as intradiscal therapies and epidural injections; and regenerative modalities with disc injections of various solutions; and, finally, surgical approaches such as fusion and artificial disc replacement 4.

Duration of Conservative Treatment

• The duration of conservative treatment for lumbar disc herniation before considering surgery is a topic of debate, with some authors recommending different time spans 5.
• A study found that patients suffering for more than 60 days from disc herniation were found to have statistically worse outcome than patients suffering for 60 days or less, suggesting that conservative treatment up to 2 months may be recommended before considering surgery 5.

Muscle Relaxants for Acute and Chronic Pain

• Muscle relaxants are used to treat acute and chronic pain, with varying degrees of efficacy and adverse effects 6, 7.
• A study found that combination therapy with cyclobenzaprine and ibuprofen was not superior to cyclobenzaprine alone in adult patients with acute neck and back pain with muscle spasm 6.
• The selection of muscle relaxants should be based on clinical indications, with consideration of their adverse effects and potential interactions with other medications 7.