What are the management options for low back pain?

From the Guidelines

Patients with low back pain should initially be treated with non-pharmacologic approaches, including superficial heat, massage, acupuncture, or spinal manipulation, as these have been shown to be effective in improving symptoms and function, according to the most recent and highest quality evidence 1. The management of low back pain involves a combination of non-pharmacological and pharmacological approaches.

Non-Pharmacological Approaches

• Superficial heat is recommended for acute or subacute low back pain, as it has been shown to have moderate-quality evidence for improving symptoms 1.
• Massage, acupuncture, and spinal manipulation are also recommended, although the evidence for these treatments is of lower quality 1.
• For patients with chronic low back pain, exercise, multidisciplinary rehabilitation, and mindfulness-based stress reduction are recommended, as they have been shown to have moderate-quality evidence for improving symptoms and function 1.

Pharmacological Approaches

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants are recommended as first-line pharmacologic treatments for patients with acute or subacute low back pain who desire medication, as they have been shown to have moderate-quality evidence for improving symptoms 1.
• For patients with chronic low back pain who have had an inadequate response to non-pharmacologic therapy, NSAIDs are recommended as first-line pharmacologic treatment, with tramadol or duloxetine as second-line options 1.
• Opioids should only be considered 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. Some key points to consider when managing low back pain include:
• Encouraging patients to remain active within pain limits and avoid bed rest, as movement helps maintain function and speeds recovery.
• Using heat or cold therapy to provide temporary relief, with heat generally preferred for chronic pain and cold for acute injuries.
• Considering complementary approaches, such as massage therapy, acupuncture, and mindfulness meditation, which have shown benefit for some patients.
• Reserving surgery for cases with specific structural problems causing neurological symptoms or after conservative treatments have failed. Most acute low back pain resolves within 4-6 weeks with appropriate management, though recurrence is common, making preventive strategies like regular exercise, maintaining healthy weight, and proper lifting techniques important components of long-term management.

From the Research

Management Options for Low Back Pain

The management of low back pain can be approached through various methods, including conservative therapy, interventional pain procedures, and surgical options. According to 2, there is a need for novel therapies to bridge the gap between conservative/interventional procedures and surgeries in patients with chronic back pain.

Conservative Therapy

Conservative therapy includes physical exercise, education, and self-management. As stated in 3, physical therapy approaches, such as exercise, are recommended for non-specific low back pain, and participation can be in a group or individual exercise program. Active strategies like exercise are related to decreased disability, while passive methods like rest and medications are associated with worsening disability.

Medications

Medications like non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat low back pain. According to 4, NSAIDs are more effective than placebo in reducing pain intensity and disability, but the magnitude of the effects is small, and the level of evidence is low. There is no difference in efficacy between different NSAID types, including selective versus non-selective NSAIDs.

Alternative Therapies

Alternative therapies like manual therapy, intensive training programs, and general practitioner programs have been evaluated for acute low-back pain. As shown in 5, patients in manual therapy and intensive training programs were more satisfied with the treatment than those in the general practitioner program, but no differences were revealed between the groups with respect to outcomes on measures of impairment, pain, functional disability, or socioeconomic disability.

Novel Therapies

Novel therapies, such as intradiscal injections, platelet-rich plasma, and stem cells, are being studied for the treatment of low back pain. According to 2, these new therapeutic options may bridge the current gap between conservative/interventional procedures and surgeries in patients with chronic back pain. Some key points to consider:

• Intradiscal therapies, including collagenase, chondroitinase, matrix metalloproteinases, and ethanol gel, are being explored as potential treatments for low back pain.
• Platelet-rich plasma and stem cells are being studied for their potential to repair damaged tissues and reduce inflammation.
• These novel therapies may offer new hope for patients with chronic low back pain who have not responded to traditional treatments.

Key Recommendations

Based on the available evidence, some key recommendations for the management of low back pain include:

• Fitness programs and advice to stay active can reduce pain, improve function, and prevent low back pain from becoming chronic 6.
• Simple analgesics, NSAIDs, and muscle relaxants can reduce pain and improve function 6.
• Maintaining physical activity, avoiding rest, and manual therapy can reduce pain and maintain function in acute low back pain 6.
• Behavioural treatment can prevent low back pain from becoming chronic 6.