Treatment of Acute Back Pain After Bending
For acute low back pain after bending, start with NSAIDs (such as ibuprofen) as first-line medication, advise the patient to remain active and avoid bed rest, and apply superficial heat for symptomatic relief. 1, 2
Initial Management Strategy
Non-Pharmacologic Interventions (Start Immediately)
Advise patients to remain active and continue ordinary activities within pain limits—bed rest provides no benefit and actually delays recovery. 1, 2, 3
Apply superficial heat using heating pads or heated blankets for short-term pain relief, which shows moderate effectiveness in the first 5 days. 1, 2, 4
Provide reassurance about the favorable prognosis—most acute back pain improves substantially within the first month, with many episodes being self-limited. 1
First-Line Pharmacologic Treatment
Prescribe NSAIDs (ibuprofen, naproxen) as the preferred first-line medication, which provide small to moderate improvements in pain intensity compared to placebo. 1, 2
Use the lowest effective NSAID dose for the shortest duration necessary, assessing cardiovascular and gastrointestinal risk factors before prescribing. 2
Acetaminophen is an acceptable alternative if NSAIDs are contraindicated, though it provides slightly less pain relief; however, it has a more favorable safety profile. 1, 2, 5
Monitor for hepatotoxicity when using acetaminophen at maximum doses (up to 3000-4000 mg/day), especially in elderly patients or those with hepatic impairment. 1, 2
Second-Line Options (If Pain Persists After 2-4 Days)
Skeletal Muscle Relaxants
Add a skeletal muscle relaxant (such as cyclobenzaprine) if NSAIDs alone are insufficient, as they improve short-term pain relief after 2-7 days compared to placebo. 2, 6
Prescribe skeletal muscle relaxants only for short periods (2-3 weeks maximum) because adequate evidence for more prolonged use is not available. 6
Warn patients about central nervous system adverse effects, primarily sedation, which occurs commonly with all skeletal muscle relaxants. 2, 6
Cyclobenzaprine should be used cautiously in patients with mild hepatic impairment, starting with 5 mg and titrating slowly upward; avoid in moderate to severe hepatic insufficiency. 6
Spinal Manipulation
- Consider spinal manipulation by appropriately trained providers (chiropractors, osteopaths, physical therapists) if initial treatments fail, as it provides small to moderate short-term benefits for acute low back pain. 1, 2, 4
Treatments to AVOID
Do NOT prescribe bed rest or activity restriction—this provides no benefit and merely prolongs recovery. 1, 2, 3
Do NOT use systemic corticosteroids, as they show no difference in pain or function compared to placebo for acute low back pain with or without sciatica. 2, 5, 4
Do NOT routinely prescribe opioids—reserve them only for severe, disabling pain not controlled with acetaminophen and NSAIDs, and only after carefully weighing substantial risks including abuse potential and addiction. 1, 2, 5
Avoid benzodiazepines as they carry risks for abuse, addiction, and tolerance; if used at all, prescribe only time-limited courses. 2
When to Reassess or Refer
Reassess patients who do not return to normal activity within 4-6 weeks, as this may indicate need for imaging or specialist evaluation. 1, 7
Screen for "red flag" findings that suggest serious underlying pathology requiring urgent evaluation: cauda equina symptoms (saddle anesthesia, bowel/bladder dysfunction), progressive neurologic deficits, fever, unexplained weight loss, history of cancer, or recent significant trauma. 1, 7, 8
Do NOT obtain routine diagnostic imaging (X-rays, MRI, CT) for nonspecific acute low back pain without red flags, as findings are often nonspecific and do not improve outcomes. 1, 4
Critical Pitfalls to Avoid
Do not extend medication courses without clear evidence of continued benefits—most acute back pain improves within days to weeks, and prolonged medication use increases adverse event risk without additional benefit. 2, 6
Do not combine NSAIDs with skeletal muscle relaxants initially—start with NSAIDs alone, adding muscle relaxants only if pain persists after several days. 2, 6
Do not prescribe exercise therapy for acute back pain—exercise shows no benefit over no exercise in the acute phase and becomes beneficial only after pain transitions to subacute or chronic phases. 4