What is the management approach for persistent back pain despite treatment with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and gabapentin, and a tapering dose of steroids?

From the Guidelines

For persistent back pain despite NSAIDs, gabapentin, and tapering steroids, a comprehensive approach including medication optimization and non-pharmacological interventions is recommended. This approach should prioritize non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, 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 1.

Medication Optimization

Consider adjusting current medications:

• Increase gabapentin to therapeutic doses (1800-3600 mg/day in divided doses)
• Optimize NSAID dosing (such as naproxen 500 mg twice daily)
• Add a muscle relaxant like cyclobenzaprine 5-10 mg at bedtime for 1-2 weeks
• For additional pain control, consider adding acetaminophen 1000 mg three times daily
• If neuropathic pain is prominent, duloxetine 30-60 mg daily may be beneficial 1

Non-Pharmacological Interventions

• Physical therapy focusing on core strengthening and flexibility should be prescribed for 6-8 weeks
• Encourage daily gentle stretching and gradual return to activity
• Consider referral for interventional pain management if pain remains severe, including epidural steroid injections for radicular symptoms
• Imaging studies (MRI) may be warranted if symptoms persist beyond 6 weeks or if there are concerning neurological findings 1

This multimodal approach addresses both pain mechanisms and functional recovery, which is more effective than medication alone for chronic back pain. Clinicians should provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options 1.

From the Research

Management Approach for Persistent Back Pain

If back pain persists despite treatment with NSAIDs and gabapentin, and tapering steroid dose, the following management approaches can be considered:

• Pharmacological Management: According to 2, baclofen, duloxetine, NSAIDs, and opiates have shown to improve pain and disability levels in patients with low back pain. However, the results must be interpreted with caution due to possible adverse events connected to the use of these drugs.
• Non-Pharmacological Approaches: As suggested by 3, non-pharmacological approaches such as self-care treatments, massage, acupuncture, spinal manipulation, and physical therapy may be recommended in combination with pharmacological treatments.
• Alternative Treatment Options: 4 recommends considering alternative treatment options such as muscle relaxants, tramadol, or tapentadol for acute low back pain that is severe or refractory.
• NSAID Therapy: 5 and 6 provide evidence that NSAIDs are effective for short-term symptomatic relief in patients with acute and chronic low back pain, but the effect sizes are small and there is no clear difference in efficacy between different types of NSAIDs.

Considerations for Treatment

When considering treatment options, the following factors should be taken into account:

• Patient Demographics: The patient's demographics, such as age and medical history, should be considered when selecting a treatment option 2.
• Adverse Events: The potential for adverse events, such as gastrointestinal bleeding or cardiovascular disease, should be considered when prescribing NSAIDs 4, 5, 6.
• Patient Compliance: Patient compliance with treatment recommendations is crucial, and patients should be educated on the importance of adhering to their treatment plan 3.