What are the guidelines for treating back pain?

From the Guidelines

For treating back pain, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for acute or subacute low back pain, and exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation for chronic low back pain. The American College of Physicians recommends these approaches based on moderate-quality evidence 1.

Key Recommendations

• For acute or subacute low back pain, nonpharmacologic treatments such as superficial heat, massage, acupuncture, or spinal manipulation are recommended as first-line therapy 1.
• For chronic low back pain, nonpharmacologic treatments including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, or spinal manipulation should be considered initially 1.
• Pharmacologic treatment with nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants may be considered for acute or subacute low back pain if nonpharmacologic treatment is not effective or desired 1.
• For patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy, may be considered 1.

Important Considerations

• Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection 1.
• Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1.
• Warning signs requiring immediate medical attention include severe pain, pain radiating down the legs, numbness or weakness, or difficulty with bladder or bowel control.

Treatment Approach

• Start with conservative measures including gradual return to activity and take over-the-counter pain medications like acetaminophen or NSAIDs for pain relief.
• Apply heat or ice for 15-20 minutes several times daily and consider gentle stretching and strengthening exercises focusing on core muscles to help prevent recurrence.
• Maintain good posture and proper body mechanics when lifting, and for persistent pain lasting more than 2-3 weeks, consult a healthcare provider who may recommend physical therapy, prescription medications, or further evaluation.

From the Research

Treatment Guidelines for Back Pain

The guidelines for treating back pain vary depending on the severity and duration of the pain.

• For acute low back pain, primary care providers typically provide advice to stay active and pharmacologic management, primarily nonsteroidal anti-inflammatory drugs 2.
• For chronic low back pain, nonpharmacologic treatments such as physical therapy, chiropractic care, massage therapy, and acupuncture are recommended 2.
• The American College of Physicians (ACP) published a clinical practice guideline for low back pain recommending nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic low back pain 2.
• The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain 3.

Pharmacological Management

• A systematic review investigated the efficacy of various pharmacological compounds to achieve pain relief and improve disability in chronic low back pain patients, and found that only baclofen, duloxetine, NSAIDs, and opiates showed improvement in pain and disability levels 4.
• However, the use of these drugs must be interpreted with caution and in the light of possible adverse events connected to their use 4.
• A randomized study compared pain and functional outcomes among patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo, and found that adding acetaminophen to ibuprofen does not improve outcomes within 1 week 5.

Nonpharmacologic Treatments

• Nonpharmacologic treatments such as physical therapy, chiropractic care, massage therapy, and acupuncture are recommended for chronic low back pain 2.
• The cost of nonpharmacologic treatments was perceived as a barrier, but primary care providers working in low-income neighborhood clinics were as likely to recommend nonpharmacologic approaches as those from a high-income neighborhood clinic 2.
• The ACP guideline recommends nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic low back pain, but further dissemination and implementation of the guideline are needed 2.