Is a multidisciplinary approach with physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and potential muscle relaxants medically indicated for a patient with a month-long history of worsening low back pain and hip girdle pain?

Yes, a multidisciplinary approach with physical therapy and NSAIDs is medically indicated for this patient with subacute low back pain and hip girdle pain.

Initial Treatment Strategy

Nonpharmacologic therapy should be the primary treatment foundation, as the American College of Physicians issues a strong recommendation that nonpharmacologic approaches are first-line for low back pain lasting beyond a few weeks 1, 2. This patient's month-long history with only mild relief from home exercises indicates the need for escalation to supervised, structured interventions.

Recommended Nonpharmacologic Interventions

Implement supervised physical therapy with individualized exercise programming that includes:

• Stretching and strengthening exercises tailored to the patient's specific deficits, which provide moderate pain relief (approximately 10 points on a 100-point scale) and functional improvement 2
• Motor control exercises, supported by moderate-quality evidence for chronic low back pain 2
• The key distinction from the patient's current home exercises is supervision and individualization—unsupervised home exercises alone are insufficient, as evidenced by this patient's continued pain 2

Multidisciplinary rehabilitation is specifically indicated for this patient who has failed initial conservative measures. The evidence shows:

• Moderately reduced short-term pain intensity (approximately 1.4-1.7 points on a 0-10 scale) compared to usual care 1
• Reduced disability (approximately 2.5-2.9 points on the Roland Disability Questionnaire) compared to usual care 1
• Superior outcomes compared to physical therapy alone, with slightly lower short-term pain and moderately lower long-term pain 1
• Greater likelihood of return to work compared to nonmultidisciplinary rehabilitation 1

Pharmacologic Therapy (Second-Line but Appropriate)

NSAIDs (naproxen or ibuprofen) are the most effective pharmacologic option and should be initiated now given the patient's continued "fair amount of pain" 2, 3:

• Moderate-quality evidence supports NSAIDs as providing superior pain relief compared to other oral medications 2
• NSAIDs are first-line pharmacologic agents for chronic low back pain 4
• Critical safety considerations: Screen for history of peptic ulcer disease, GI bleeding, renal impairment, cardiovascular disease, and concurrent anticoagulant use before prescribing 5
• Use the lowest effective dose for the shortest duration to minimize GI and renal risks 5
• Patients over 65 or with prior GI issues have >10-fold increased risk of GI bleeding and require extra caution 5

Consider duloxetine (30-60 mg daily) as an alternative or adjunct if NSAIDs are contraindicated or if neuropathic pain features are present (burning, shooting pain, numbness beyond mechanical distribution) 2.

What NOT to Do (Critical Pitfalls)

Do not order imaging (MRI, X-ray, CT) at this stage unless red flags develop 2, 3:

• Imaging findings are often nonspecific and do not improve outcomes in nonspecific low back pain 3
• Red flags requiring immediate imaging/referral include: progressive neurologic deficits, new urinary retention or incontinence, saddle anesthesia, bilateral leg weakness, or suspected cauda equina syndrome 6, 3

Do not pursue interventional procedures (epidural injections, facet joint injections, radiofrequency ablation) for this axial low back pain without radicular features 2:

• The American College of Physicians strongly recommends against these procedures for non-radicular low back pain as they do not improve morbidity or quality of life 2

Muscle relaxants are NOT recommended as primary therapy despite the question's mention of them:

• Guidelines do not support muscle relaxants as a standard component of multidisciplinary care for subacute/chronic low back pain 1
• They may cause sedation and dependency without clear evidence of superior efficacy 4

Additional Considerations

Assess for psychosocial yellow flags that predict chronicity: depression, anxiety, fear-avoidance behaviors, catastrophizing, or job dissatisfaction 3:

• If present, add cognitive-behavioral therapy or mindfulness-based stress reduction (moderate-quality evidence for chronic low back pain) 1, 2

Emphasize staying active and avoiding bed rest—activity promotes recovery while rest leads to deconditioning 2, 3.

Reassess in 4-6 weeks: If pain persists despite optimized nonpharmacologic and pharmacologic therapy, refer to multidisciplinary pain management 2.

Clinical Reasoning

This patient has subacute low back pain (one month duration) that is transitioning toward chronic pain, with inadequate response to home exercises alone. The evidence hierarchy clearly prioritizes multidisciplinary rehabilitation over single-modality physical therapy for patients like this 1. The combination of supervised exercise, NSAIDs, and potentially psychological support addresses the biopsychosocial nature of low back pain more effectively than any single intervention 7, 8. The patient's continued pain with standing and walking indicates functional impairment that warrants this escalated, coordinated approach rather than continuing ineffective home exercises.