What is the recommended treatment plan for a patient with acute back pain?

Recommended Treatment Plan for Acute Back Pain

For acute low back pain, start with NSAIDs (ibuprofen 400-800mg every 6-8 hours), superficial heat therapy, and advice to remain active while avoiding bed rest, with the addition of a short-term muscle relaxant at bedtime if severe pain persists. 1, 2

Immediate First-Line Management

Pharmacologic Therapy

• Initiate ibuprofen 600-800mg every 6-8 hours for 3-4 days consistently, as NSAIDs provide moderate-quality evidence for small to moderate pain reduction in acute low back pain 1, 3
• The FDA-approved dosing range is 1200-3200mg daily, with individual doses not exceeding 800mg 3
• Take with meals or milk if gastrointestinal complaints occur 3

Non-Pharmacologic Therapy

• Apply superficial heat (heating pad, heat wrap, or heated blanket) for 20-30 minutes, 2-3 times daily, which provides moderate-quality evidence for pain relief within 5 days and improved disability scores 1, 4
• If heat worsens pain, discontinue and use ice only 1
• Heat wrap therapy combined with exercise provides greater pain relief at 7 days compared to exercise alone 1

Activity Modification

• Advise patients to stay active and continue ordinary activities within pain limits, as bed rest leads to deconditioning and worse outcomes 1, 2
• Avoid sudden and excessive back movements during the acute phase 5, 6

Second-Line Management for Persistent Severe Pain

Muscle Relaxant Addition

• Add a skeletal muscle relaxant (cyclobenzaprine preferred) at bedtime for 1-2 weeks maximum if pain remains severe despite NSAIDs and heat 2, 7
• Cyclobenzaprine has the strongest evidence among muscle relaxants for acute low back pain 2
• Critical safety warnings: Do not drive, operate heavy machinery, or care for small children while taking muscle relaxants due to sedation risk 2, 7
• Do not combine with alcohol or other sedating medications 2
• Do not extend use beyond 1-2 weeks, as no evidence supports longer duration and risks of sedation, falls, and cognitive impairment increase 2, 7

Early Mobilization Phase (After 2-3 Days)

Range of Motion Exercises

• Begin gentle range of motion exercises 1-2 times daily once acute pain begins to subside (typically after 2-6 days) to preserve function 1
• Supervised exercise therapy is not effective for acute low back pain (<4 weeks duration), but early mobilization prevents deconditioning 1

Additional Non-Pharmacologic Options if Pain Persists Beyond 1 Week

Spinal Manipulation

• Consider spinal manipulation if pain persists beyond 1 week, as it provides small to moderate short-term benefits for acute low back pain 1
• Low-quality evidence shows spinal manipulation combined with exercise or advice slightly improves function at 1 week 1

Red Flag Assessment Requiring Immediate ER Evaluation

Seek immediate emergency care if any of the following develop:

• Fever or chills (suggesting infection) 8, 6
• Sudden weakness in arms or legs (suggesting cauda equina syndrome or severe neurologic compromise) 8, 6
• Saddle anesthesia (numbness or tingling in the perineal/genital region) 8, 6
• Loss of bowel or bladder control (suggesting cauda equina syndrome requiring urgent surgical evaluation) 8, 6

Follow-Up Strategy

• If symptoms do not improve within 7 days, refer to a back specialist for further evaluation 2, 6
• Reassess at 4-6 weeks if pain persists, as 90% of acute low back pain resolves with conservative management 5, 8
• Imaging is not indicated initially unless red flags are present, as it does not improve outcomes and may lead to unnecessary interventions 2, 9

Medications to Explicitly Avoid

• Do not prescribe systemic corticosteroids, as they show no superiority over placebo for low back pain with or without sciatica 1, 2
• Avoid benzodiazepines entirely, as they are ineffective for back pain and carry substantial risks of abuse, addiction, and tolerance 7
• Reserve opioids only as a last resort after all other options have failed, given limited evidence for modest short-term effects and significant risks 1, 7

Common Pitfalls to Avoid

• Do not prescribe prolonged bed rest (>2-3 days), as it worsens outcomes through deconditioning 1, 2, 8
• Do not continue muscle relaxants beyond 1-2 weeks, as there is no evidence for efficacy in prolonged use and risks escalate 2, 7
• Do not order routine imaging without red flags, as it does not improve outcomes and increases unnecessary interventions 2, 9