What are the recommended treatments for back pain?

From the Guidelines

For back pain, the most effective treatment approach typically begins with nonpharmacologic therapies, including superficial heat, massage, acupuncture, or spinal manipulation, as these have been shown to provide moderate to low-quality evidence of improvement in back-specific and overall function. According to the most recent and highest quality study 1, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for acute or subacute low back pain. If pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants may be considered, as they have moderate-quality evidence supporting their use.

Some key points to consider in the treatment of back pain include:

• The use of nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants for pharmacologic treatment, as recommended by 1
• The importance of nonpharmacologic therapies, such as 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, for patients with chronic low back pain, as recommended by 1
• The consideration of pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy, for patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, as recommended by 1
• The potential benefits and risks of opioid therapy, which should only be considered in patients who have failed other treatments and after a discussion of known risks and realistic benefits with patients, as recommended by 1

It is essential to note that the treatment approach should be individualized, taking into account the patient's specific needs and circumstances. The goal of treatment should be to improve back-specific and overall function, reduce work disability and return to work, and enhance health-related quality of life, while minimizing adverse effects. As stated in 1, the target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

From the FDA Drug Label

In patients with mild to moderate pain secondary to postoperative, orthopedic, postpartum episiotomy and uterine contraction pain and dysmenorrhea. Onset of pain relief can begin within 30 minutes in patients taking naproxen sodium Analysis of the data from controlled studies shows that cyclobenzaprine produces clinical improvement whether or not sedation occurs

The recommended treatments for back pain include naproxen and cyclobenzaprine.

• Naproxen may be used to treat mild to moderate pain, with onset of pain relief beginning within 30 minutes.
• Cyclobenzaprine has been shown to produce clinical improvement in patients with back pain, regardless of sedation. 2 3

From the Research

Recommended Treatments for Back Pain

The following are recommended treatments for back pain based on available evidence:

• Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat people with low back pain, especially people with acute back pain 4, 5, 6.
• Short-term NSAID use is also recommended for pain relief in people with chronic back pain 4.
• The combination of muscle relaxants and NSAIDs may be more effective than NSAIDs alone in managing acute low back pain 7, 8.
• There is no clear difference in efficacy between different types of NSAIDs, including selective and non-selective NSAIDs 4, 5, 6.

Efficacy of NSAIDs

The efficacy of NSAIDs in treating back pain is supported by several studies:

• A 2016 Cochrane review found that NSAIDs are more effective than placebo in reducing pain intensity and disability in people with chronic low back pain 4.
• A 2019 study found that the combination of chlorzoxazone and ibuprofen is more effective than ibuprofen alone in managing acute low back pain 7.
• A 2020 study found that the combination of eperisone hydrochloride and ibuprofen is more effective than ibuprofen alone in reducing symptoms of acute non-specific back pain with muscle spasm 8.
• A 2020 Cochrane review found that NSAIDs are slightly more effective than placebo in reducing pain intensity and disability in people with acute low back pain, but the magnitude of the effects is small and probably not clinically relevant 6.

Safety of NSAIDs

The safety of NSAIDs is a concern, particularly with long-term use:

• A 2016 Cochrane review found that adverse events are not statistically significant more frequent in participants using NSAIDs compared to placebo, but the review noted that the proportion of patients experiencing an adverse event is likely underestimated due to the relatively small sample size and short follow-up in most included trials 4.
• A 2020 Cochrane review found that there is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events when using NSAIDs compared to placebo, and that the safety of NSAIDs for longer-term use is uncertain 6.