Management of Acute Back Pain
For acute back pain, stay active and avoid bed rest, use NSAIDs (ibuprofen 400mg every 4-6 hours) or acetaminophen as first-line medication, and apply superficial heat for short-term relief. 1, 2
Immediate Non-Pharmacological Management
Staying active is the cornerstone of treatment. Continue ordinary activities within the limits permitted by pain—bed rest is ineffective and should be avoided as it leads to deconditioning and worsens outcomes. 3, 1, 2
Apply superficial heat using heating pads or heated blankets for short-term pain relief, which provides moderate pain relief at 5 days and shows superior effectiveness compared to acetaminophen or ibuprofen after 1-2 days. 3, 1, 2
Use a medium-firm mattress rather than a firm mattress if you need to optimize sleeping surface. 3, 1
Avoid imaging unless red flags are present (progressive neurologic deficits, suspected infection, malignancy, or cauda equina syndrome) or there is no improvement after 6 weeks. 3, 2
First-Line Pharmacological Treatment
NSAIDs are the preferred first-line medication with moderate-quality evidence showing small improvement in pain intensity compared to placebo. 1, 2
Ibuprofen 400mg every 4-6 hours as needed for pain relief (maximum 3200mg daily, though doses greater than 400mg per dose were no more effective in controlled trials). 4, 5
Acetaminophen (up to 3000mg/day) is an alternative first-line option with a more favorable safety profile, particularly for elderly patients, though it may provide slightly less pain relief than NSAIDs. 1, 2
Avoid systemic corticosteroids as low-quality evidence shows no difference in pain or function compared with placebo. 1, 2
Second-Line Options if Pain Persists
Skeletal muscle relaxants (such as cyclobenzaprine) can be considered if pain persists after 2-7 days, with moderate-quality evidence showing improved short-term pain relief compared to placebo. 1
Cyclobenzaprine is associated with drowsiness and dry mouth as common side effects. 6
Spinal manipulation may provide small to moderate short-term benefits if administered by appropriately trained providers. 3, 2
Critical Reassurance and Education
Provide evidence-based reassurance that acute low back pain has a generally favorable prognosis with a high likelihood for substantial improvement in the first month (90% of episodes resolve within 6 weeks). 3, 2
Explain that early routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses. 3
Self-care education materials based on evidence-based guidelines (such as The Back Book) are recommended as an inexpensive method for supplementing clinician-provided information. 3
Common Pitfalls to Avoid
Do not prescribe bed rest—it is ineffective and leads to worse outcomes. 3, 1, 5
Do not routinely order imaging in the absence of red flags, as findings are often nonspecific and do not improve outcomes. 3, 2
Avoid opioids unless severe, disabling pain is not controlled with acetaminophen and NSAIDs, and only after carefully weighing potential benefits and harms. 1
Do not use systemic corticosteroids—they lack evidence of efficacy. 1, 2
When to Reassess
Reassess if symptoms persist beyond 4-6 weeks despite conservative management, at which point consider imaging (MRI preferred if available) and specialist referral. 3, 2