Low back pain: causes, treatment and warning signs

Acute low back pain usually starts with a sudden injury to the muscles or ligaments that support the back. It can come from lifting something heavy, a sudden movement or sitting for a long time.

Other causes include muscle spasms, a herniated disk and sciatica (pain that runs down the leg). Staying active helps more than bed rest. If the pain is higher up, see neck pain.

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The most common symptoms of low back pain are:

• Pain or stiffness in the lower back
• Muscle spasms
• Pain that gets worse when you move, bend or lift
• Pain that runs down one leg (sciatica)

These steps, based on MedlinePlus and NICE guidance, help most people:

• Cut back a little for the first few days, but avoid bed rest: ease back into your normal activities.
• Use ice for the first 48 to 72 hours, then heat.
• Sleep in a comfortable position, with a pillow between your knees if you sleep on your side.
• After 2 to 3 weeks, start gentle aerobic activity such as walking, cycling or swimming.
• Physical therapy can teach you exercises and how to move safely.
• Back belts and corsets are not recommended for low back pain.

Once the doctor or your physical therapist says you can start stretching, gentle hip mobility exercises can help you keep moving comfortably.

Medication. Over-the-counter pain relievers such as acetaminophen or the anti-inflammatories ibuprofen or naproxen can help when used as directed. Anti-inflammatories are not right for everyone (for example with stomach, kidney or heart problems), so the doctor checks which is safe for you. For back pain that lasts for months, the FDA label for duloxetine includes chronic musculoskeletal pain. If appropriate, she prescribes another medicine.

Tests. X-rays and MRIs are usually not needed in the first 4 to 6 weeks if there are no warning signs; clinical guidelines advise against routine imaging. If the pain lasts more than 4 weeks, spreads below the knee, is worse when lying down, or comes with numbness or weakness in your legs, the doctor gives you an order for the imaging or lab test you need, or guides you to physical therapy.

A muscle relaxer is one of the options for acute low back pain. The American College of Physicians (ACP, 2017) guideline recommends starting with superficial heat, massage, acupuncture or spinal manipulation, because most people improve over time; if medicine is needed, the options it recommends are an anti-inflammatory (NSAID) or a skeletal muscle relaxant.

What is cyclobenzaprine used for? Cyclobenzaprine (formerly sold as Flexeril) is a prescription muscle relaxer. According to its FDA-approved label, it is used along with rest and physical therapy to relieve muscle spasm from an acute, painful injury, such as a back strain. It is a prescription medicine for short-term use: the label says up to 2 or 3 weeks, and MedlinePlus advises not taking it for more than 3 weeks without talking to your doctor.

What to know before you take it, according to the FDA label and MedlinePlus:

• It makes you drowsy. Drowsiness and dry mouth are its most common side effects. Do not drive or operate machinery until you know how it affects you.
• Do not mix it with alcohol: cyclobenzaprine increases the effects of alcohol and of other medicines that make you sleepy.
• Adults 65 and older: usually should not take it, because it is not as safe or effective as other options; they have a higher risk of confusion and falls.
• Other medicines: it is not used with MAO inhibitors or within 14 days of stopping one, and with some antidepressants, tramadol or bupropion it can cause serotonin syndrome. Tell the doctor everything you take.
• It is not for everyone: the label rules it out if you have hyperthyroidism, an irregular heart rhythm, heart failure or a recent heart attack.

In your video visit, at any hour, the doctor reviews your pain, your age, your other conditions and the medicines you take, and decides whether a muscle relaxer is appropriate for you or another option fits better. If appropriate, she prescribes and we send your prescription to your pharmacy. Book your visit.

Sciatica is not a disease but a symptom: pain, weakness, numbness or tingling down the leg because something presses on the sciatic nerve. According to MedlinePlus, the most common causes are a herniated disk, spinal stenosis and piriformis syndrome. It usually affects one leg, can reach the foot and gets worse after sitting or standing for a long time.

It often gets better on its own, though it can come back. Staying active instead of resting in bed, ice or heat, core exercises and over-the-counter pain relievers help; the doctor evaluates you by video and tells you what fits your case. Go to the ER if you lose control of urine or stool, the groin or buttocks go numb, or the leg is very weak.

Back pain is less common in children, and we see children of all ages with a parent or legal guardian on camera. If your child has back pain with fever, weight loss or pain that wakes them at night, the doctor evaluates them and, if needed, gives you a lab or imaging order. For their safety, if the pain started after a fall or a hard blow, go to the emergency room.

For your safety, call 911 or go to the emergency room if you have any of these signs. More in when to go to the ER.

• Loss of bladder or bowel control
• Numbness in the groin, buttocks or inner thighs
• Weakness in the legs or trouble walking
• Fever with back pain
• Pain after a fall or a hard blow