What are the best treatments for a sore lower back?

Treatment for Sore Lower Back

Start with NSAIDs and staying active—these are your first-line treatments with the strongest evidence for both acute and chronic low back pain. 1, 2

Immediate Assessment Priorities

Before initiating treatment, quickly rule out serious pathology by checking for:

• Progressive motor or sensory deficits (requires urgent imaging) 3
• Cauda equina syndrome (new urinary retention/incontinence, saddle anesthesia—requires emergency intervention) 4, 3
• Infection or malignancy red flags (fever, unexplained weight loss, history of cancer, immunosuppression) 3
• Significant trauma relative to age (consider fracture risk, especially in elderly or those with osteoporosis) 3

Do not obtain imaging initially unless red flags are present—most low back pain improves within 4-6 weeks regardless of treatment, and early imaging does not improve outcomes. 4, 3

First-Line Treatment (Start Here)

Pharmacologic Management

NSAIDs are the most effective first-line medication with moderate-quality evidence showing small to moderate pain relief (5-20 points on 100-point scale) superior to all other oral medications. 1, 2

• Prescribe ibuprofen or naproxen at the lowest effective dose for the shortest duration to minimize gastrointestinal and cardiovascular risks 2, 4
• Acetaminophen is NOT recommended as the first large placebo-controlled trial showed it was completely ineffective for acute low back pain (no difference from placebo) 1
• For elderly patients with NSAID contraindications, acetaminophen may be used despite limited efficacy, with maximum 4g/day and liver function monitoring 4

Non-Pharmacologic Management (Equally Important)

Advise patients to remain active and avoid bed rest—this is critical as activity promotes recovery while rest leads to deconditioning and worsens outcomes. 1, 5, 2

• Heat application (heating pads, heated blankets) provides short-term relief for acute pain 5
• Medium-firm mattresses are preferable to firm mattresses 5
• Continue ordinary activities within pain limits 5

Second-Line Treatment (If Pain Persists After 1-2 Weeks)

For Acute Pain (<4 weeks)

Skeletal muscle relaxants show moderate-quality evidence for improved short-term pain relief after 2-7 days, but cause significant sedation—prescribe time-limited courses only (typically 5-7 days). 1, 5, 4

Spinal manipulation by trained providers (chiropractors, osteopaths, physical therapists) shows small to moderate short-term benefits and can be considered as part of comprehensive treatment. 2, 4

For Chronic Pain (>12 weeks)

Exercise therapy is the cornerstone of chronic low back pain management with moderate evidence for both pain relief (approximately 10 points on 100-point scale) and functional improvement—individualized, supervised programs incorporating stretching and strengthening show best outcomes. 1, 2, 6

Specific exercise modalities with proven efficacy:

• Yoga (Viniyoga or Iyengar styles) demonstrates moderate superiority over self-care with sustained benefits at 26 weeks and decreased medication use 2
• Tai chi has moderate-quality evidence supporting effectiveness 2
• Motor control exercises have moderate-quality evidence 2

Duloxetine 30-60 mg daily is specifically recommended as second-line pharmacologic therapy for chronic low back pain, particularly beneficial if neuropathic pain component exists (burning, shooting pain). 2

Additional evidence-based options for chronic pain:

• Acupuncture (moderate evidence) 2
• Massage therapy 2, 4
• Cognitive-behavioral therapy or mindfulness-based stress reduction, especially if psychological factors present (fear-avoidance, catastrophizing, depression) 2, 4

What NOT to Do (Critical Pitfalls)

Do NOT use systemic corticosteroids—moderate-quality evidence shows no difference in pain or function compared to placebo, with increased risk of insomnia, nervousness, and increased appetite. 1, 5

Do NOT perform interventional procedures for non-radicular (axial) low back pain—epidural injections, facet joint injections, and radiofrequency ablation do not improve morbidity or quality of life. 2

Do NOT prescribe opioids as first or second-line therapy—reserve only for severe, disabling pain uncontrolled by NSAIDs after documented failure of all above treatments, and only when benefits clearly outweigh substantial risks of abuse and addiction. 2, 4, 7

Tramadol is an alternative second-line option but still carries opioid-related risks. 2

When to Refer or Escalate

Immediate specialist consultation required for:

• Progressive neurological deficits 2
• Cauda equina syndrome 2
• Suspected infection or malignancy 2

Refer to multidisciplinary pain management if:

• Pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months 2
• Significant psychological comorbidities (depression, anxiety) interfering with recovery 1, 2

Consider MRI only if:

• Patient is potential candidate for surgery or epidural steroid injection AND symptoms persist beyond 4-6 weeks 4
• Red flags are present 4
• Prefer MRI over CT for superior soft-tissue contrast without radiation 4

Expected Outcomes

Most patients improve within 4-6 weeks regardless of treatment, though up to one-third may have persistent moderate pain at one year—setting realistic expectations is essential. 4