What is the recommended treatment for acute back sprain?

Treatment of Acute Back Sprain

First-Line Treatment: Stay Active and Use NSAIDs

For acute back sprain, advise patients to remain active and avoid bed rest, while prescribing NSAIDs as first-line medication, with superficial heat application for additional symptomatic relief. 1

Non-Pharmacologic Management (Start Immediately)

• Advise patients to stay active and continue ordinary activities within pain limits – bed rest causes deconditioning, prolongs recovery, and delays return to work 2, 1
• Patients prescribed only 2 days of bed rest missed 45% fewer work days (3.1 vs 5.6 days) compared to 7 days of bed rest, with no difference in clinical outcomes 3
• Apply superficial heat using heating pads or heated blankets – provides moderate pain relief at 5 days and improved disability at 4 days 2, 1
• Heat combined with exercise provides greater pain relief at 7 days than exercise alone 2

First-Line Pharmacologic Treatment

• Prescribe NSAIDs (such as ibuprofen 400 mg every 4-6 hours, maximum 3200 mg daily) as the preferred first-line medication – provides small to moderate improvements in pain intensity compared to placebo 2, 1

• Use the lowest effective dose for the shortest duration necessary 1

• Assess cardiovascular and gastrointestinal risk factors before prescribing, as NSAIDs carry CV thrombotic, GI bleeding, and renal risks 1

• No head-to-head trials show meaningful differences between different NSAIDs, so selection can be based on cost and availability 1

• Acetaminophen is an acceptable alternative due to favorable safety profile, though it shows no significant difference from placebo for pain intensity or function 1

• Monitor for hepatotoxicity when using maximum doses, especially in elderly patients or those with hepatic impairment 1

Second-Line Treatment: Add Muscle Relaxants for Severe Spasm

• For severe pain with muscle spasm not controlled by NSAIDs, add a skeletal muscle relaxant for short-term use (2-3 weeks maximum) 1, 4
• Cyclobenzaprine has the strongest evidence among muscle relaxants and is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 4
• All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation 1
• Do not extend muscle relaxant use beyond 2-3 weeks – adequate evidence of effectiveness for more prolonged use is not available 4
• No compelling evidence exists that different skeletal muscle relaxants differ in efficacy or safety 1

When Initial Treatment Fails (After 1-2 Weeks)

• Consider spinal manipulation administered by appropriately trained providers – associated with small to moderate short-term benefits for acute low back pain 2, 1
• The evidence is insufficient to conclude that benefits vary according to the profession of the manipulator (chiropractor vs. other clinician trained in manipulation) 2

Opioid Considerations (Use Only as Last Resort)

• Opioid analgesics or tramadol may be considered only when severe, disabling pain is not controlled with acetaminophen and NSAIDs 1
• Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction, requiring careful weighing of benefits and harms before initiating therapy 1

Critical Pitfalls to Avoid

• Do NOT prescribe bed rest or activity restriction – provides no benefit and delays recovery, with patients returning to work 45% faster with minimal bed rest 1, 3
• Do NOT prescribe systemic corticosteroids – they are no more effective than placebo for acute low back pain with or without sciatica 2, 1
• Do NOT use benzodiazepines routinely – they show similar effectiveness to skeletal muscle relaxants but carry risks for abuse, addiction, and tolerance; if used, only prescribe time-limited courses 1
• Do NOT prescribe antidepressants or antiseizure medications – insufficient evidence exists for their use in acute low back pain 1
• Do NOT order routine imaging without red flags – does not improve outcomes and may lead to unnecessary interventions 1
• Do NOT extend medication courses without clear evidence of continued benefits and absence of major adverse events 2, 1

Expected Clinical Course and Patient Education

• Reassure patients that 90% of acute low back pain episodes resolve within 6 weeks regardless of treatment 5
• Most patients experience rapid improvement in pain, disability, and return to work within the first month 2
• Advise patients that minor flare-ups may occur in the subsequent year 5

Red Flags Requiring Urgent Evaluation

• Consider imaging or specialist referral if patients have: history of trauma, fever, incontinence, unexplained weight loss, cancer history, long-term steroid use, parenteral drug abuse, severe neurologic deficits, or cauda equina syndrome 6, 5
• Suspect cauda equina syndrome or severe or progressive neurological deficit if red flags are present 5