What are the treatments for chronic lower back pain?

From the Guidelines

To treat chronic lower back pain, start with nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation, as recommended by the American College of Physicians 1.

Nonpharmacologic Treatments

• Exercise regularly: Focus on low-impact activities like walking, swimming, or cycling for 30 minutes, 3-5 times per week, as well as core-strengthening exercises and gentle stretches daily.
• Try physical therapy: Attend sessions 2-3 times per week for 4-6 weeks to learn specific exercises and techniques for managing pain.
• Practice good posture and ergonomics: Maintain proper alignment when sitting, standing, and lifting objects, and use supportive chairs and mattresses.
• Consider alternative therapies: Acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation may be beneficial.

Pharmacologic Treatments

If nonpharmacologic treatments are ineffective, consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, or tramadol or duloxetine as second-line therapy, as recommended by the American College of Physicians 1.

• Use NSAIDs: Try ibuprofen (400-800 mg every 6-8 hours) or naproxen (220-440 mg every 12 hours) for pain relief.
• Consider alternative medications: Tramadol or duloxetine may be used as second-line therapy if NSAIDs are ineffective.

Important Considerations

• Opioids should only be considered as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients, after a discussion of known risks and realistic benefits with patients 1.
• Regular follow-up with a healthcare provider is essential to monitor treatment effectiveness and adjust the treatment plan as needed.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.

The treatment for chronic lower back pain may include ibuprofen tablets. The recommended dose for mild to moderate pain is 400 mg every 4 to 6 hours as necessary for relief of pain 2.

• Key points to consider:
  • Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.
  • Do not exceed 3200 mg total daily dose.
  • If gastrointestinal complaints occur, administer ibuprofen tablets with meals or milk.
• Important: The FDA drug label does not provide a direct answer to the question of treatments for chronic lower back pain specifically, but ibuprofen can be used for mild to moderate pain.

From the Research

Treatments for Chronic Lower Back Pain

• Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat people with low back pain, especially people with acute back pain, and short term NSAID use is also recommended for pain relief in people with chronic back pain 3
• Physical therapy models, including exercise and manual therapy interventions, are recommended for the treatment of low back pain, with the aim of improving function and preventing disability from getting worse 4, 5
• Active strategies such as exercise are related to decreased disability, while passive methods (rest, medications) are associated with worsening disability, and are not recommended 5
• Evidence-based interventions for chronic low back pain include duloxetine, acceptance and commitment therapy, classification-based exercise and manual therapy intervention, and self-management approaches 6
• Pharmacological compounds that have shown efficacy in achieving pain relief and improving disability in chronic low back pain patients include baclofen, duloxetine, NSAIDs, and opiates, although the results must be interpreted with caution and in the light of possible adverse events connected to the use of these drugs 7

Types of NSAIDs

• Two types of NSAIDs are available and used to treat back pain: non-selective NSAIDs and selective COX-2 NSAIDs 3
• There is no difference in efficacy between different NSAID types, including selective versus non-selective NSAIDs 3

Exercise and Physical Therapy

• Exercise is recommended as a first-line treatment for chronic low back pain, and can be used in combination with other non-pharmacological therapies such as tai chi, yoga, massage, and spinal manipulation 5
• A classification-based exercise and manual therapy intervention is a leading evidence-based treatment for chronic low back pain 6

Pharmacological Management

• The most effective pharmacological therapy for chronic low back pain is controversial, and the choice of treatment should be based on individual patient needs and demographics 7
• Baclofen, duloxetine, NSAIDs, and opiates have shown efficacy in achieving pain relief and improving disability in chronic low back pain patients, although the results must be interpreted with caution and in the light of possible adverse events connected to the use of these drugs 7