What are the treatment options for neck and back pain?

Treatment Options for Neck and Back Pain

For both neck and back pain, nonpharmacologic therapies should be the first-line treatment, with medications used as adjuncts when needed. 1

Acute Pain Management (Duration <4 weeks)

Nonpharmacologic Approaches

• Self-care options:
  • Remain active and continue normal daily activities as tolerated
  • Apply heat using heating pads or heated blankets 1
  • Avoid prolonged bed rest (can worsen outcomes)

Professional Interventions

• Spinal manipulation administered by trained providers (chiropractor or other qualified clinician) - shows small to moderate short-term benefits 1
• Physical therapy consultation - particularly beneficial if pain persists beyond initial self-care

Pharmacologic Options

If medication is desired:

• First-line: NSAIDs like ibuprofen 1, 2
  • Use lowest effective dose for shortest duration
  • Caution in patients with cardiovascular disease, renal impairment, or GI bleeding history
  • Monitor for side effects (GI upset, increased blood pressure)
• Alternative: Skeletal muscle relaxants like cyclobenzaprine 1, 3
  • Effective for short-term relief
  • Primary side effect is sedation
  • Start with 5mg dose in patients with mild hepatic impairment

Subacute Pain Management (4-12 weeks)

Nonpharmacologic Approaches

• Intensive interdisciplinary rehabilitation - moderately effective 1
• Functional restoration with cognitive-behavioral component - reduces work absenteeism 1
• Exercise therapy - begin after initial acute phase

Pharmacologic Options

• Continue NSAIDs if effective and well-tolerated
• Consider short-term muscle relaxants for muscle spasm
• Avoid opioids - not recommended for routine use in subacute pain 1

Chronic Pain Management (>12 weeks)

Nonpharmacologic Approaches (Strong Recommendation)

• Exercise therapy - particularly programs with individual tailoring, supervision, stretching, and strengthening 1
• Multidisciplinary rehabilitation 1
• Mind-body practices:
  • Yoga (particularly Viniyoga-style) 1
  • Tai chi 1
  • Mindfulness-based stress reduction 1
• Manual therapies:
  • Massage therapy 1
  • Spinal manipulation 1
• Other effective options:
  • Acupuncture 1
  • Cognitive-behavioral therapy 1
  • Progressive relaxation 1

Pharmacologic Options

For patients with inadequate response to nonpharmacologic therapy:

• First-line: NSAIDs 1
• Second-line: Duloxetine (SNRI) 1
• For neuropathic pain: Consider gabapentin, pregabalin, or lidocaine patches 1
• Last resort: Tramadol or other opioids only after failure of other treatments and when benefits clearly outweigh risks 1

Important Considerations

Specific Exercise Recommendations

• McKenzie exercises plus stabilization exercises - shown to be more effective than McKenzie exercises alone for chronic neck pain 4
• Exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening show best outcomes 1

Interventions to Avoid

• Strong recommendations against for chronic spine pain 1:
  • Joint radiofrequency ablation
  • Epidural injections of local anesthetic, steroids, or combinations
  • Joint-targeted injections
  • Intramuscular injections of local anesthetic with/without steroids

Special Populations

• Older adults:
  • Use tricyclic antidepressants judiciously due to risks of confusion and falls 1
  • Consider lower starting doses of muscle relaxants
  • NSAIDs should be used with greater caution

Cost Considerations

• Low-cost options to integrate exercise include walking in public spaces or using public recreation facilities 1
• Physical therapy consultation within 48 hours for acute pain and within 10 days for all patients with back pain may decrease rate of surgical interventions 5

Treatment Algorithm

1. Initial approach: Self-care with heat application and maintaining activity
2. If pain persists:
   • For acute pain: Add spinal manipulation and/or NSAIDs/muscle relaxants
   • For subacute/chronic pain: Begin structured exercise program and consider referral for physical therapy
3. For chronic pain not responding to initial measures:
   • Implement multimodal approach combining exercise, mind-body practices, and manual therapies
   • Add NSAIDs if not contraindicated
4. For persistent pain despite above measures:
   • Consider second-line medications (duloxetine)
   • Evaluate for specialized interventions through multidisciplinary rehabilitation

Remember that patient expectations of benefit from treatment should be considered when choosing interventions, as they can influence outcomes 1.