Management of Lumbar Strain
For acute lumbar strain, advise patients to remain active and avoid bed rest, provide NSAIDs or acetaminophen for pain relief, and consider adding heat therapy and spinal manipulation for symptom control. 1
Initial Assessment and Red Flags
When evaluating lumbar strain, perform a focused history and physical examination specifically looking for:
- Red flags indicating serious pathology (fracture, infection, cauda equina syndrome) that require immediate imaging and specialist referral 1
- Yellow flags (psychosocial risk factors, fear-avoidance behaviors, depression) that predict chronicity and disability 1
- Neurological deficits suggesting radiculopathy (straight leg raise, motor/sensory changes) 1
Do not order routine imaging for uncomplicated lumbar strain—imaging is only indicated when red flags are present, neurological deficits exist, or pain persists despite 6 weeks of conservative therapy 1, 2.
First-Line Management: Activity and Self-Care
Patients must avoid bed rest entirely—remaining active is more effective than bed rest for acute low back pain 1, 3. Even 48 hours of bed rest shows worse outcomes compared to staying mobile 3.
Provide self-care education materials (such as evidence-based booklets) that emphasize:
- Return to normal activities as quickly as tolerable 1
- Staged resumption of work and daily activities 1
- Benefits of remaining active and harms of prolonged rest 1
Apply superficial heat using heating pads or heated blankets for short-term pain relief 1.
Pharmacologic Management
Start with acetaminophen or NSAIDs as first-line medication 1, 2. While NSAIDs provide slightly better pain relief than acetaminophen (approximately 10 points on a 100-point scale), acetaminophen has a more favorable safety profile and lower cost 1.
When prescribing NSAIDs:
- Assess cardiovascular and gastrointestinal risk factors before prescribing 1
- Use the lowest effective dose for the shortest duration necessary 1
- Be aware of increased myocardial infarction risk with both COX-2 selective and most nonselective NSAIDs 1
Muscle relaxants like cyclobenzaprine can be used as adjuncts for short periods (2-3 weeks maximum) to relieve muscle spasm associated with acute painful musculoskeletal conditions 4. However, evidence for muscle relaxants in chronic low back pain is inconclusive 2.
Avoid opioids—there is insufficient evidence to recommend long-term opioid use for chronic low back pain 2.
Non-Pharmacologic Interventions
For patients not improving with initial management, add:
Spinal manipulation is recommended as it shows moderate effectiveness for low back pain 1, 5. This involves manual therapy with high-velocity thrusts applied to spinal joints beyond their restricted range 1.
Massage therapy using soft tissue manipulation can provide benefit 1.
Exercise therapy should be initiated, including:
- Directional preference exercises (McKenzie method) 5, 6
- Individualized physical activity programs 6
- Strength training as pain allows 6
The McKenzie method shows similar effectiveness to other structured exercise programs and can be integrated into multimodal treatment 5.
Progression to Subacute/Chronic Management
If symptoms persist beyond 6 weeks despite conservative treatment:
Add neurodynamic mobilization and continue strength training 6. Consider transforaminal or epidural injections for radicular symptoms, though evidence shows only limited benefit 6, 7.
For chronic pain (>12 weeks):
- Combine spinal manipulative therapy with specific exercise programs 6
- Add function-specific physical training 6
- Provide individualized vocational, ergonomic, and postural advice 6
- Consider duloxetine as it may provide benefit for chronic low back pain 2
Refer to comprehensive rehabilitation programs incorporating cognitive-behavioral therapy if pain remains refractory—these are equivalent alternatives to fusion surgery for 1-2 level degenerative disc disease without stenosis 1.
Interventions to Avoid
Do not prescribe bed rest—it worsens outcomes 1, 3.
Do not use lumbar braces or supports—there is no benefit for preventing back injuries, compliance is poor (42%), and they may increase risk of lower back pain 8.
Avoid routine imaging in the absence of red flags or neurological deficits 1, 2.
Do not use TENS, traction, or shortwave diathermy as routine interventions—evidence for these modalities is insufficient 1.
Special Considerations
For workers with lumbar strain, assess age, general health, and physical job demands when advising about activity limitations 1. Brief individualized educational interventions can reduce sick leave in workers with subacute low back pain 1.
A medium-firm mattress is superior to a firm mattress for patients with chronic low back pain 1.
Younger age, female gender, and lower BMI are associated with better treatment responses in acute lumbar strain 9.