What is the treatment for back strain?

Treatment of Back Strain

For acute back strain, start with superficial heat application (heating pad or heat wrap) combined with NSAIDs or acetaminophen, advise the patient to remain active and avoid bed rest, and reassure them that 90% of cases resolve within 6 weeks. 1, 2, 3

Initial Management (First 48-72 Hours)

First-Line Pharmacologic Treatment

• NSAIDs (ibuprofen) 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 1, 2
• Acetaminophen (up to 3000mg/day) is an acceptable alternative for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain 1, 2, 3
• Avoid systemic corticosteroids entirely as they have not shown greater efficacy than placebo 4, 3

First-Line Nonpharmacologic Treatment

• Apply superficial heat using heating pads or heat wraps for 30 minutes at a time, which provides moderate pain relief superior to acetaminophen or ibuprofen after 1-2 days 4, 1, 2
• Heat wrap therapy shows consistent evidence of moderate superiority to placebo for short-term pain relief and functional status in acute low back pain 4, 1
• Cold packs provide similar pain relief to heat, so choice should be based on patient preference 5

Activity Modification

• Advise patients to remain active and continue ordinary activities within pain limits - this is critical as activity restriction prolongs recovery 4, 1, 2, 3
• Explicitly instruct patients to avoid bed rest, as it is associated with increased disability and worse outcomes 4, 3
• Reassure patients that 90% of acute back strain episodes resolve within 6 weeks regardless of treatment 3

Second-Line Treatment (If Inadequate Response After 3-5 Days)

Muscle Relaxants

• Consider skeletal muscle relaxants (cyclobenzaprine 5-10mg three times daily) for short-term relief when muscle spasm contributes to pain, but prescribe time-limited courses only (2-3 weeks maximum) 2, 6
• Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 6
• Be aware of sedation risk as a central nervous system adverse effect, and start with 5mg dose in elderly or hepatically impaired patients 6

Manual Therapy

• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits for acute pain and can be considered as part of a comprehensive treatment plan 4, 1, 2
• Spinal manipulation was found moderately superior to sham treatment in higher-quality trials for acute low back pain 4

What NOT to Do: Common Pitfalls

Avoid Unnecessary Imaging

• Do not obtain routine imaging (X-rays, MRI, CT) for nonspecific back strain without red flags, as findings are often nonspecific and do not improve outcomes 4, 1, 3
• Only perform MRI or CT when severe/progressive neurologic deficits are present (weakness, numbness, loss of bowel/bladder control), serious underlying conditions are suspected, or symptoms persist beyond 4-6 weeks in surgical candidates 4, 1, 2

Avoid Ineffective Treatments

• Do not use traction - multiple higher-quality trials found traction no more effective than placebo, sham, or no treatment for any outcome 4, 1
• Avoid TENS (transcutaneous electrical nerve stimulation) - higher-quality trials found no differences between TENS and sham TENS for any measured outcome 4
• Do not prescribe shortwave diathermy or ultrasonography, as evidence shows no benefit over sham treatment 4

Avoid Premature Exercise Therapy

• For acute back strain, structured exercise therapy shows no benefit over no exercise - the Cochrane review found no difference in pain relief or functional outcomes 1
• Exercise therapy becomes beneficial only after pain transitions to subacute (4-12 weeks) or chronic phases (>12 weeks) 1

Transition to Subacute/Chronic Management (If Symptoms Persist Beyond 4 Weeks)

Expand Treatment Options

• Add exercise therapy with individualized, supervised programs incorporating stretching and strengthening 4, 1
• Consider acupuncture, massage therapy, cognitive-behavioral therapy, or yoga for chronic symptoms 4, 1, 2
• Intensive interdisciplinary rehabilitation with cognitive-behavioral components can reduce work absenteeism in subacute cases 4, 1

Red Flags Requiring Immediate Evaluation

• Severe or progressive neurologic deficits (weakness, numbness, loss of bowel/bladder control) require immediate medical attention 4, 2, 3
• Suspicion of cauda equina syndrome, infection, malignancy, or spinal fracture requires urgent imaging and specialist referral 4, 2

Expected Outcomes and Patient Education

• Most patients experience rapid improvement in pain, disability, and ability to return to work within the first month 4, 3
• Up to one-third of patients may have persistent moderate pain at one year, so early identification of psychosocial risk factors (depression, anxiety, job dissatisfaction, fear-avoidance beliefs) is important 4, 2, 3
• Provide evidence-based self-care education materials that encourage return to normal activity, adoption of fitness programs, and appropriate lifestyle modification 4, 3