What are the treatment options for severe lower back tenderness?

Treatment of Severe Lower Back Tenderness

Begin with NSAIDs (ibuprofen or naproxen) at the lowest effective dose combined with advice to remain active and avoid bed rest—this combination provides the most effective initial management for severe lower back tenderness. 1, 2, 3

First-Line Treatment: Nonpharmacologic Therapy Plus Medication

Immediate Activity Recommendations

• Remain active and continue ordinary activities within pain limits—this is a strong recommendation based on moderate-quality evidence showing better outcomes than rest. 1, 2, 4
• Explicitly avoid bed rest, as it increases disability and worsens outcomes. 2, 4
• Apply superficial heat using heating pads or heated blankets for short-term pain relief, which provides moderate pain relief at 5 days. 2, 4
• Combining heat with exercise provides greater pain relief than exercise alone at 7 days. 2

First-Line Pharmacologic Options

• NSAIDs (ibuprofen, naproxen) are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen. 1, 2, 3
• Prescribe at the lowest effective dose for the shortest duration necessary due to gastrointestinal, renovascular, and cardiovascular risks (including increased myocardial infarction risk). 1
• Assess cardiovascular and gastrointestinal risk factors before prescribing; consider co-administration with a proton-pump inhibitor in higher-risk patients. 1
• Acetaminophen is an acceptable alternative for patients with NSAID contraindications, though it is slightly weaker (less than 10 points on a 100-point pain scale) and shows no significant difference from placebo in acute low back pain. 1, 3, 4
• Maximum acetaminophen dose is 4g/day, but be aware of asymptomatic aminotransferase elevations even in healthy adults. 1

Second-Line Treatment Options

When First-Line Therapy Is Insufficient

• Skeletal muscle relaxants (cyclobenzaprine, tizanidine) are an option for short-term relief when muscle spasm contributes to pain, but all are associated with central nervous system adverse effects, primarily sedation. 1, 3, 5
• Prescribe time-limited courses only (up to 2-3 weeks), as adequate evidence for more prolonged use is not available. 5
• Spinal manipulation by appropriately trained providers shows small to moderate short-term benefits and can be considered as part of comprehensive treatment. 1, 2, 3

For Severe, Disabling Pain Uncontrolled by NSAIDs

• Opioid analgesics or tramadol are an option when used judiciously for severe, disabling pain that is not controlled with acetaminophen and NSAIDs. 1, 3
• Carefully weigh potential benefits and harms before starting therapy due to substantial risks, including aberrant drug-related behaviors, abuse, and addiction with long-term use. 1
• Failure to respond to a time-limited course should lead to reassessment and consideration of alternative therapies or referral. 1

Additional Effective Nonpharmacologic Options for Chronic or Persistent Pain

Exercise-Based Therapies

• Exercise therapy is the cornerstone of treatment for chronic low back pain, with moderate-quality evidence showing small to moderate improvements in pain and function (approximately 10 points on a 100-point scale). 2
• Individualized, supervised programs incorporating stretching and strengthening produce the best outcomes. 2
• Motor control exercises specifically target coordination, control, and strength of spinal-supporting muscles, moderately decreasing pain scores with sustained benefits. 2

Mind-Body and Manual Therapies

• Yoga demonstrates moderate superiority over self-care education with sustained benefits at 26 weeks. 2
• Tai chi has moderate-quality evidence for pain improvement at 3 and 6 months. 2
• Massage therapy shows moderate effectiveness for chronic low back pain. 1, 2
• Cognitive-behavioral therapy or mindfulness-based stress reduction should be considered, particularly if psychological factors are present. 2

Critical Red Flags Requiring Immediate Evaluation

Urgent Referral Indicators

• Progressive neurologic deficits (weakness, numbness, loss of bowel/bladder control) require immediate medical attention. 2, 4, 6, 7
• Cauda equina syndrome (bilateral neurologic deficits, saddle anesthesia, urinary retention) requires urgent surgical referral. 6, 7, 8
• Suspected infection or malignancy requires immediate medical attention. 2, 3, 4, 7
• Significant trauma related to age or suspected fracture requires immediate evaluation. 7, 8

What to AVOID: Critical Pitfalls

Interventions That Do Not Improve Outcomes

• The American College of Physicians issues strong recommendations against epidural injections, facet joint injections, radiofrequency ablation, and intramuscular trigger point injections for axial spine pain—these procedures do not improve morbidity, mortality, or quality of life. 2
• Do not routinely obtain imaging (X-rays, MRI, CT) unless red flags are present or symptoms persist beyond 4-6 weeks, as findings are often nonspecific and do not improve outcomes. 2, 3, 4, 9, 10
• TENS shows no benefit compared to sham TENS. 2
• Lumbar supports have not shown clear benefits. 2
• Systemic corticosteroids should be avoided as they have not shown greater efficacy than placebo. 4

When to Refer to Specialist

• Refer to multidisciplinary pain management if pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months. 2
• Immediate specialist consultation is required for red flags: progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy. 2, 6, 7

Expected Outcomes and Patient Counseling

• Reassure patients that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment, with most patients experiencing rapid improvement within the first month. 4, 10
• The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate, with effects on function generally smaller than effects on pain. 2
• Up to one-third may have persistent moderate pain at one year, warranting ongoing management strategies. 3