What is the plan of care for a patient presenting with lumbar musculoskeletal strain after lifting a heavy object, experiencing moderate lower back pain and taking Advil (ibuprofen)?

From the Guidelines

For a patient with a musculoskeletal strain from lifting a heavy box who reports 5/10 lower back pain and is taking Advil, I recommend a comprehensive care plan combining medication, physical measures, and activity modification. Continue the Advil (ibuprofen) 400-600mg every 6 hours as needed for pain, not exceeding 3200mg daily, for 5-7 days, as suggested by the guidelines for the treatment of low back pain 1. Apply ice packs to the lower back for 15-20 minutes every 2-3 hours during the first 48-72 hours to reduce inflammation, then transition to heat therapy using a heating pad for 15-20 minutes several times daily to promote blood flow and healing. Rest is important initially, but complete bed rest should be avoided; instead, maintain light activity while avoiding movements that worsen pain, as recommended for patients with acute low back pain 1. Begin gentle stretching exercises like knee-to-chest pulls and pelvic tilts after acute pain subsides, typically within 2-3 days. Proper body mechanics are essential for recovery - bend at the knees when lifting, keep objects close to the body, and avoid twisting. If pain persists beyond 2 weeks, worsens, or if neurological symptoms develop (numbness, weakness, or radiating pain), seek further medical evaluation, following the guidelines for the evaluation and treatment of low back pain 1. This approach addresses both pain management and functional recovery by reducing inflammation, promoting tissue healing, and preventing deconditioning that can prolong recovery. Some key points to consider in the management of low back pain include:

• Providing patients with evidence-based information on low back pain with regard to their expected course, advising patients to remain active, and providing information about effective self-care options 1
• Considering the addition of nonpharmacologic therapy with proven benefits for patients who do not improve with self-care options, such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation 1
• Evaluating patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals [see WARNINGS] Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.

The patient is experiencing 5/10 lower back pain and is taking Advil (ibuprofen).

• The recommended dose for mild to moderate pain is 400 mg every 4 to 6 hours as necessary.
• The patient should be advised to take the lowest effective dose for the shortest duration consistent with individual patient treatment goals.
• The patient's dose should be reviewed and adjusted as required.
• It is essential to monitor the patient for signs and symptoms of GI bleeding, and to discontinue the NSAID if a serious GI event is suspected 2.
• The patient should be informed of the warning signs and symptoms of hepatotoxicity, and to stop therapy and seek immediate medical therapy if these occur 2.
• The patient should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible 2.

From the Research

Patient Assessment

• The patient is presenting with musculoskeletal strain after lifting a heavy box, experiencing 5/10 lower back pain.
• The patient is currently taking Advil (ibuprofen) for pain management.

Treatment Options

• Topical therapies, such as capsaicin and topical diclofenac, have been shown to be effective in treating chronic soft-tissue pain and may be considered as an adjunct to oral pain management 3, 4.
• Topical NSAIDs have been found to provide relief superior to placebo and comparable to oral ibuprofen in patients with knee osteoarthritis 3.
• However, a randomized controlled trial found that compounded topical pain creams were not better than placebo creams in treating localized chronic pain 5.

Pain Management

• Ibuprofen has been consistently shown to be superior to paracetamol (acetaminophen) in a range of painful conditions, including acute post-operative pain, dysmenorrhoea, and osteoarthritis 6.
• The patient's current use of Advil (ibuprofen) may be effective in managing their lower back pain, but the dosage and frequency of administration should be monitored and adjusted as needed.

Plan of Care

• Continue to monitor the patient's pain levels and adjust their treatment plan as needed.
• Consider adding topical therapies, such as capsaicin or topical diclofenac, to the patient's treatment plan if their pain persists or worsens 3, 4.
• Educate the patient on proper lifting techniques and ergonomics to prevent future musculoskeletal strains.