What are the recommendations for managing severe back pain caused by muscle spasms?

From the Guidelines

For severe back muscle spasms, I recommend a multi-faceted approach combining rest, medication, and gentle movement, prioritizing the use of skeletal muscle relaxants such as cyclobenzaprine (Flexeril) 5-10mg three times daily or methocarbamol (Robaxin) 750mg every 4 hours for short-term use (3-7 days) to reduce muscle tension, as they have been found to be moderately superior to placebo for short-term pain relief 1. Start with over-the-counter pain relievers like ibuprofen (Advil, Motrin) at 400-600mg every 6 hours or naproxen (Aleve) at 220-440mg every 12 hours with food to reduce inflammation and pain. Apply heat therapy using a heating pad for 15-20 minutes several times daily to relax tight muscles, alternating with cold packs (20 minutes on, 20 minutes off) to reduce inflammation during the first 48-72 hours. Some key points to consider:

• Gentle stretching exercises like knee-to-chest pulls, pelvic tilts, and gentle back extensions can help once the acute pain subsides.
• These treatments work because muscle spasms often result from inflammation, muscle strain, or protective guarding.
• Anti-inflammatories reduce chemical mediators of pain, heat increases blood flow to deliver nutrients and remove waste products, while muscle relaxants decrease nerve signals causing muscle contractions.
• If pain is severe, persists beyond 1-2 weeks, includes numbness/tingling, or is accompanied by fever or bladder/bowel problems, seek immediate medical attention as these could indicate more serious conditions. It's also important to note that benzodiazepines, although effective for short-term pain relief, are associated with risks for abuse, addiction, and tolerance, and their use should be limited to a time-limited course of therapy 1. Additionally, herbal therapies such as devil's claw, willow bark, and capsicum may be safe options for acute exacerbations of chronic low back pain, but their benefits range from small to moderate 1. Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1. Nonpharmacologic therapies such as spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation may also be considered for patients who do not improve with self-care options 1.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living Cyclobenzaprine hydrochloride tablets should be used only for short periods (up to two or three weeks)

Recommendations for muscle spasms in back causing severe pain:

• Cyclobenzaprine hydrochloride tablets may be used as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions.
• The medication should be used for short periods only (up to two or three weeks) 2.
• Key considerations: relief of muscle spasm and its associated signs and symptoms, such as pain.

From the Research

Treatment Options for Muscle Spasms in Back Causing Severe Pain

• Muscle relaxants, such as cyclobenzaprine, can be effective in treating acute neck or back pain with muscle spasm 3
• Combination therapy with cyclobenzaprine and ibuprofen may not be superior to cyclobenzaprine alone in adult patients with acute neck and back pain with muscle spasm 3
• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be superior to placebo for reducing pain in acute and chronic low back pain 4
• Muscle relaxants may be superior to placebo for reducing pain in acute low back pain, but their effects are unclear for chronic low back pain 4

Medication Selection and Safety

• Appropriate medication selection based on clinical indications is important when using muscle relaxants for acute and chronic pain 5
• Muscle relaxants, NSAIDs, and other medications can have adverse effects, and their use should be carefully considered and monitored 3, 5, 4
• Medications such as paracetamol, opioid analgesics, antibiotics, and antidepressants should only be prescribed after a discussion between the treating clinician and the patient, considering the risks and possible benefits 4