What are the treatment options for a patient with mechanical lower back pain?

What to Tell Your Patient with Mechanical Lower Back Pain

Stay active, avoid bed rest, and start NSAIDs like ibuprofen 400 mg every 4-6 hours—this combination provides the fastest recovery for mechanical back pain. 1, 2

Immediate Reassurance and Activity Guidance

• Provide strong reassurance that 90% of acute back pain episodes resolve within 6 weeks regardless of treatment, with most patients showing substantial improvement within the first month. 1, 3

• Emphasize that bed rest is harmful—it causes muscle deconditioning, atrophy, and slower recovery compared to staying active. 2, 3

• Instruct the patient to continue ordinary activities within pain limits, as those who maintain normal activities recover faster than those who rest or do specific exercises in the acute phase. 3

• Early return to work (even modified duty) is associated with less long-term disability. 3

First-Line Pharmacologic Treatment

• Prescribe NSAIDs as first-line medication—ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily) provides superior pain relief compared to acetaminophen or other oral medications. 2

• Use the lowest effective dose for the shortest duration, and assess cardiovascular and gastrointestinal risk factors before prescribing, as NSAIDs carry CV thrombotic, GI bleeding, and renal risks. 2

• Acetaminophen is an acceptable alternative only for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain. 4

First-Line Nonpharmacologic Treatment

• Recommend superficial heat application (heat wraps) for 20-30 minutes, 3-4 times daily—this provides moderate pain relief at 5 days and shows superior pain relief compared to acetaminophen or ibuprofen after 1-2 days. 1, 3

• Consider spinal manipulation by appropriately trained providers (chiropractor, osteopath, or physical therapist), which provides small to moderate short-term benefits for acute pain. 1, 3, 4

• Massage and acupuncture are additional options with low-quality evidence supporting their use in acute pain. 1

When to Add Muscle Relaxants

• For severe pain with muscle spasm, add a skeletal muscle relaxant like cyclobenzaprine for short-term use (1-2 weeks maximum). 2, 5

• Cyclobenzaprine has the strongest evidence among muscle relaxants but causes sedation as a central nervous system adverse effect. 2, 5

• Do not extend muscle relaxant use beyond 2-3 weeks—there is no evidence supporting longer duration and sedation risks increase. 2, 5

Specific Activity Modifications (First 48-72 Hours)

• Limit activities that significantly worsen pain while maintaining general mobility—avoid heavy lifting, forceful twisting, and explosive movements. 3

• Avoid prolonged sitting or standing; alternate positions frequently to prevent stiffness. 3

• No high-impact activities (jumping, running, contact sports) until pain substantially improves. 3

If Pain Persists Beyond 4 Weeks (Subacute Phase)

• Add intensive interdisciplinary rehabilitation or functional restoration with cognitive-behavioral components to reduce work absenteeism. 1, 3

• Consider MRI only if the patient is a potential candidate for surgery or epidural steroid injection and symptoms persist beyond 4-6 weeks. 4

If Pain Becomes Chronic (>12 Weeks)

• Prioritize exercise therapy as the cornerstone of treatment—individualized, supervised programs incorporating stretching and strengthening produce the best outcomes. 1, 2, 3

• Add multidisciplinary options: acupuncture, yoga, tai chi, mindfulness-based stress reduction, cognitive-behavioral therapy, massage therapy, or progressive relaxation. 1

• For inadequate response to nonpharmacologic therapy, consider tramadol or duloxetine as second-line pharmacologic options. 1

Critical Pitfalls to Avoid

• Do NOT prescribe systemic corticosteroids—they are no more effective than placebo for low back pain. 2, 3

• Do NOT order routine imaging without red flags (progressive neurologic deficits, cauda equina symptoms, suspected infection/malignancy, significant trauma)—it does not improve outcomes and may lead to unnecessary interventions. 2, 3

• Do NOT recommend prolonged bed rest—this is the single most harmful intervention you can prescribe. 2, 3

• Avoid opioids except in severe, disabling pain uncontrolled by NSAIDs, given substantial risks of abuse and addiction. 4

Red Flags Requiring Urgent Evaluation

• Progressive motor or sensory loss, new urinary retention or overflow incontinence (cauda equina syndrome). 6

• History of cancer, recent invasive spinal procedure, or significant trauma relative to age. 6

• Fever, unexplained weight loss, or immunosuppression suggesting infection or malignancy. 4