What is the best management approach for a patient presenting with lumbar strain?

Management of Lumbar Strain

For uncomplicated lumbar strain without red flags, initiate conservative management immediately with NSAIDs, encourage continued activity while avoiding bed rest, and defer imaging entirely unless symptoms persist beyond 6 weeks. 1, 2

Initial Assessment and Red Flag Screening

Screen immediately for red flags that would alter management:

• Progressive neurological deficits, motor weakness, or sensory changes 2, 3
• Cauda equina symptoms (urinary retention, saddle anesthesia, bowel dysfunction) 3
• Night pain or constant pain unrelieved by rest 2
• Fever, unexplained weight loss, or history of cancer suggesting infection or malignancy 4

If any red flags are present, obtain urgent MRI within 2 weeks and refer to specialist services. 2, 3

First-Line Pharmacological Management

Start NSAIDs (such as naproxen) as first-line therapy, using the lowest effective dose for the shortest duration necessary. 2, 4

• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 2
• Acetaminophen is a reasonable alternative if NSAIDs are contraindicated, though it provides slightly weaker analgesia 2, 4
• Avoid muscle relaxants and opiates, as they have not been shown to be more effective than NSAIDs for acute low back pain 4

Activity Modification and Patient Education

Advise patients to remain physically active and continue ordinary activities within pain limits—bed rest is contraindicated and inferior to staying active. 1, 2, 3, 4

• Reassure patients that 90% of acute lumbar strain episodes resolve within 6 weeks regardless of treatment 4
• Educate about proper body mechanics and safe back exercises for injury prevention 4
• Apply ice to painful areas and recommend stretching exercises 4
• Encourage early return to work, which is associated with less disability 4

Physical Therapy Referral Strategy

Do not refer all patients to physical therapy—use risk stratification after 2 weeks to direct resources appropriately. 2

• For low-risk patients: Provide self-management resources including online materials and evidence-based educational materials 2
• For medium-risk patients: Refer to physiotherapy for supervised exercise programs incorporating stretching and strengthening 2
• If referring for physical therapy, ensure it is goal-directed manual therapy, not passive modalities like heat, traction, or ultrasound 4

Imaging Guidelines

Defer all imaging (radiography, MRI, CT) in the initial evaluation of uncomplicated lumbar strain without red flags. 1

The evidence is unequivocal on this point: routine imaging provides no clinical benefit in uncomplicated low back pain and leads to increased healthcare utilization. 1 Many MRI abnormalities are seen in asymptomatic individuals and do not correlate with symptoms. 1, 3

Consider MRI lumbar spine without contrast only if symptoms persist or progress after 6 weeks of optimal conservative management and the patient is a candidate for intervention. 1, 3

Timeline for Specialist Referral

• Urgent referral (within 2 weeks): If pain is disabling or motor/sensory deficits are present 2
• Routine referral (by 3 months): If symptoms persist despite conservative management, with earlier referral if pain severity increases or functional disability worsens 2

Critical Pitfalls to Avoid

• Never prescribe bed rest—staying active is superior for back pain management 2, 4
• Avoid early imaging without red flags—this leads to unnecessary interventions and increased healthcare costs 1, 3
• Do not use "physical therapy for all" approach—stratify patients by risk level to allocate resources appropriately 2
• Avoid focusing on imaging findings rather than clinical presentation—disc abnormalities are common in asymptomatic individuals 3