What are the treatment options for lower back pain that occurs after bending down?

Treatment for Lower Back Pain After Bending

Start with staying active and using NSAIDs like ibuprofen 400 mg every 4-6 hours, avoiding bed rest entirely, as this approach provides the best outcomes for mechanical low back pain triggered by bending. 1, 2

Immediate First-Line Management

Stay Active - Most Critical Step

• Continue normal activities within pain limits rather than resting in bed, as bed rest causes deconditioning and worse outcomes 1, 2, 3
• Return to work and daily activities as soon as tolerable, which reduces disability 1, 4
• Reassure yourself that 90% of episodes resolve within 6 weeks regardless of treatment 4

Pain Relief Medications

• Take ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily) as your first medication choice, as NSAIDs provide superior pain relief compared to acetaminophen 3, 5
• Use the lowest effective dose for the shortest duration to minimize cardiovascular, gastrointestinal, and kidney risks 1, 3
• Acetaminophen is an alternative if you have risk factors for NSAID complications, though it's slightly less effective 5

Adjunctive Measures

• Apply superficial heat to the painful area for short-term relief (effective at 5 days) 2, 3
• Perform gentle stretching exercises within your pain tolerance 4

If Pain Persists Beyond 1-2 Weeks

Add Muscle Relaxant for Severe Spasm

• Consider cyclobenzaprine 5-10 mg three times daily if muscle spasm is prominent, but limit use to 1-2 weeks maximum 3, 6
• Expect sedation as a common side effect; avoid driving or operating machinery 6
• Do not extend beyond 2-3 weeks as there's no evidence supporting longer duration 6

Non-Pharmacologic Therapies (After 2-6 Weeks)

• Spinal manipulation by a trained provider (chiropractor, osteopath, or physical therapist) shows small to moderate short-term benefits for acute pain 1, 2
• McKenzie exercises are particularly helpful if pain radiates below the knee 4
• Goal-directed manual physical therapy is more effective than passive modalities like heat, ultrasound, or TENS 4

For Chronic or Persistent Pain (Beyond 4-8 Weeks)

Evidence-Based Non-Pharmacologic Options

• Exercise therapy with individual tailoring, supervision, stretching, and strengthening provides the best outcomes (10-point improvement on 100-point pain scale) 1, 2
• Acupuncture shows moderate effectiveness for chronic pain 1, 2
• Massage therapy demonstrates similar efficacy to other effective interventions 1, 2
• Viniyoga-style yoga is slightly superior to traditional exercises 1, 2
• Cognitive-behavioral therapy or progressive relaxation reduces pain by 10-20 points on a 100-point scale 1, 2

Additional Medication Options for Chronic Pain

• Tricyclic antidepressants provide pain relief for chronic pain with neuropathic components 1, 3
• Gabapentin may help if there are radicular symptoms (pain radiating down the leg) 1, 2, 3
• Duloxetine is preferred when NSAIDs provide inadequate response, particularly with neuropathic features 3

Critical Pitfalls to Avoid

What NOT to Do

• Do NOT rest in bed for more than a day or two, as this worsens outcomes and causes deconditioning 1, 2, 3
• Do NOT take systemic corticosteroids (prednisone, methylprednisolone), as they are no more effective than placebo 1, 2, 3
• Do NOT get imaging (X-ray, MRI, CT) unless you have red flags, as routine imaging doesn't improve outcomes and may lead to unnecessary interventions 2, 3
• Do NOT use TENS units, as they have not been proven effective 1, 7
• Do NOT use traction devices, as they show no benefit 1

Red Flags Requiring Immediate Medical Evaluation

Seek urgent care if you develop:

• Progressive leg weakness or numbness 2
• New inability to urinate or loss of bowel control (cauda equina syndrome - medical emergency) 2
• Fever, unexplained weight loss, or history of cancer 2, 4
• Severe trauma relative to your age 2
• Pain that worsens at night or at rest 4

Treatment Algorithm Summary

Week 1-2: Stay active + ibuprofen 400 mg every 4-6 hours + heat application 1, 2, 3

Week 2-4: Add spinal manipulation if not improving + consider short course of cyclobenzaprine if severe muscle spasm 1, 2, 6

Week 4-8: Begin supervised exercise therapy with stretching and strengthening 1, 2

Beyond 8 weeks: Add acupuncture, massage, yoga, or cognitive-behavioral therapy as adjuncts to exercise 1, 2

Throughout: Avoid bed rest, avoid imaging without red flags, avoid systemic steroids 1, 2, 3