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266 Neck and back pain – mechanical strain
n Summary and recommendations
First line: NSAIDs (e.g. ibuprofen 600–800 mg PO TID)
Reasonable:
n oral opioids (e.g. oxycodone 5–10 mg q4–6 h, with or without acetaminophen)
n cyclobenzaprine 5 mg PO TID or methocarbamol 1000 mg PO QID
Pregnancy: acetaminophen (650–1000 mg PO QID), oral opioids (e.g.
oxycodone 5–10 mg PO q4–6 h), cyclobenzaprine (5 mg PO TID)
Pediatric: NSAIDs (e.g. ibuprofen 10 mg/kg PO QID)
Special cases:
n NSAIDs and opioids not indicated, or benzodiazepines previously efficacious:
benzodiazepines (e.g. diazepam 5 mg PO QID)
n discrete trigger points identified on examination: injection with local anesthetics
(e.g. lidocaine)
n refractory symptoms, opioids are to be avoided: combination therapy with
NSAID (e.g. ibuprofen 600–800 mg PO TID) and a skeletal muscle relaxant
(e.g. cyclobenzaprine 5 mg PO TID)
References
1. Bigos S, Bowyer O, Braen G. Clinical Practice Guideline No. 14: Acute Low Back
Problems in Adults. [AHCPR Publication 95–0642.] Rockville, MD: Agency for
Health Care Policy and Research, 1994.
2. Beebe FA, Barkin RL, Barkin S. A clinical and pharmacologic review of skeletal
muscle relaxants for musculoskeletal conditions. Am J Ther. 2005;12(2):
151–171.
3. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and
chronic nonspecific low back pain. A systematic review of randomized controlled
trials of the most common interventions. Spine. 1997;22(18):2128–2156.
4. van Tulder MW, Scholten RJ, Koes BW, et al. Nonsteroidal anti-inflammatory
drugs for low back pain: a systematic review within the framework of the
Cochrane Collaboration Back Review Group. Spine. 2000;25(19):2501–2513.