From the Guidelines
Ariana Gomez should be referred to physical therapy for her persistent neck and back pain following the motor vehicle accident, as this approach is supported by the most recent and highest quality evidence available, such as the guidelines from the American College of Physicians and the American Pain Society 1. She should also pick up and begin taking the prescribed muscle relaxant as directed, while continuing with over-the-counter pain management using Tylenol (acetaminophen) and/or ibuprofen as needed. Given her difficulty carrying her infant son, physical therapy will be particularly beneficial to address functional limitations and prevent chronic pain development. The absence of neurological symptoms such as numbness, tingling, weakness, or bowel/bladder issues is reassuring, suggesting no nerve compression requiring urgent intervention. However, if she develops any of these symptoms, she should seek immediate medical attention. Physical therapy will help through targeted exercises to strengthen supporting muscles, improve range of motion, and teach proper body mechanics for childcare activities. The combination of medication for symptom relief and physical therapy for functional improvement represents the standard of care for post-MVA neck and back pain without neurological compromise, as recommended by guidelines such as those from the British Pain Society 1. Key points to consider in her management include:
- The importance of remaining active and avoiding prolonged bed rest, as recommended by guidelines 1
- The potential benefits of psychological therapies in managing chronic pain, although the evidence is still evolving 1
- The need for careful selection and monitoring of patients undergoing spinal interventions, such as radiofrequency denervation, to ensure optimal outcomes 1 Overall, a multidisciplinary approach incorporating physical therapy, medication, and education on self-management strategies is likely to provide the best outcomes for Ariana Gomez, in terms of reducing morbidity, mortality, and improving quality of life.
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 The patient was prescribed a muscle relaxer, likely cyclobenzaprine, for neck and back pain after a motor vehicle accident.
- Indication: The patient's condition, muscle spasm associated with acute, painful musculoskeletal conditions, matches the indication for cyclobenzaprine.
- Use: Cyclobenzaprine should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available. The patient has not yet started taking the medication, but it may be beneficial for relief of muscle spasm associated with her condition 2.
From the Research
Patient Presentation and History
- Ariana Gomez, a 37-year-old female, presents with neck and back pain following a motor vehicle accident (MVA) where she was a restrained passenger.
- The patient denies airbag deployment, loss of consciousness (LOC), or hitting her head during the accident.
- She reports ongoing neck and back pain, which sometimes makes it difficult to carry her almost 3-month-old baby boy.
- The patient denies any urinary/bowel incontinence, loss of sensation, numbness, tingling, or weakness.
Initial Treatment and Current Request
- Initially, the patient was recommended to take Tylenol and/or ibuprofen for pain management and was prescribed a muscle relaxer, which she has not picked up.
- The patient is now requesting a referral to physical therapy (PT) for her ongoing symptoms.
Relevant Studies on Pain Management
- A study on ibuprofen 3 highlights its efficacy and safety profile for pain relief, including its use in managing musculoskeletal conditions.
- Another study 4 discusses pharmacologic therapy for acute pain, suggesting acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatments, with adjunctive medications like muscle relaxants for specific conditions.
- Research on cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm 5 found that combination therapy was not superior to cyclobenzaprine alone, with all treatments being well-tolerated.
- A functional MRI study 6 explored brain activation patterns during acute impact pain and mechanical hyperalgesia, investigating the effects of cyclooxygenase inhibitors.
- A study on the concomitant use of ibuprofen and paracetamol 7 found that the risks of major clinical safety outcomes do not appear to be modified by concomitant use compared to using either drug alone.