What are the recommended treatment options for chronic back pain?

Treatment Options for Chronic Back Pain

For chronic low back pain, the most effective treatment options include cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation, all of which have good evidence for moderate efficacy. 1

First-Line Non-Pharmacological Therapies

Evidence-Based Therapies for Chronic Low Back Pain

• Exercise therapy - Good evidence for moderate efficacy 1

  • Programs that incorporate individual tailoring, supervision, stretching, and strengthening show best outcomes 2
  • Should be started after the acute phase (2-6 weeks) 2
  • Benefits over placebo or no treatment average 10-20 points on a 100-point pain scale 1

• Cognitive-behavioral therapy - Good evidence for moderate efficacy 1

  • Particularly helpful for addressing psychological factors that contribute to pain perception 2

• Spinal manipulation - Good evidence for moderate efficacy 1

  • No conclusive evidence that benefits vary by profession of manipulator 2
  • Provides small to moderate benefits 1

• Interdisciplinary rehabilitation - Good evidence for moderate efficacy 1

  • Combines physical, psychological, and educational interventions 1
  • Particularly effective for complex cases with significant disability 2

Additional Effective Therapies

• Massage - Fair evidence for effectiveness in chronic low back pain 1
• Yoga (Viniyoga) - Fair evidence for effectiveness 1
• Functional restoration - Fair evidence for effectiveness 1
• Acupuncture - Fair evidence for effectiveness 1
• Heat application - Good evidence for moderate benefits in acute pain, may help in chronic cases 1, 2

Second-Line Pharmacological Therapies

Medications should be considered only after non-pharmacological approaches or as adjuncts:

• NSAIDs - First-line medication option with moderate-quality evidence for small to moderate pain improvement 2, 3

  • Use lowest effective dose for shortest period necessary due to potential side effects 2
  • Caution in older adults due to gastrointestinal, renal, and cardiovascular risks 2

• Duloxetine (SNRI) - Moderate-quality evidence for effectiveness in chronic low back pain 2, 3

• Tricyclic antidepressants - Effective for chronic low back pain 2

  • Selective serotonin reuptake inhibitors have not shown effectiveness 2

• Gabapentin - Small, short-term benefits for patients with radiculopathy/sciatica 2

Ineffective or Not Recommended Treatments

• Traction - Not shown to be effective for sciatica 2
• Transcutaneous electrical nerve stimulation (TENS) - Not proven effective for chronic low back pain with sciatica 2
• Bed rest - Should be avoided as it can worsen disability 3
• Long-term opioids - Evidence is inconclusive to recommend their use 3
• Routine imaging - Not recommended for nonspecific low back pain 2

Implementation Strategy

1. Start with active approaches:

   • Structured exercise program (physical therapy)
   • Remain active and continue normal daily activities as much as pain allows
   • Apply heat therapy for short-term relief

2. Add psychological interventions if pain persists:

   • Cognitive behavioral therapy
   • Mindfulness-based stress reduction

3. Consider manual therapies:

   • Spinal manipulation
   • Massage

4. Add medications only if necessary:

   • NSAIDs (if no contraindications)
   • Consider duloxetine or tricyclic antidepressants for persistent pain

5. For radicular symptoms (sciatica):

   • Consider gabapentin for short-term relief 2

Common Pitfalls to Avoid

• Relying solely on passive treatments - Active strategies like exercise are associated with decreased disability, while passive methods (rest, medications alone) are associated with worsening disability 4

• Overuse of imaging - Routine diagnostic imaging is not recommended for nonspecific low back pain as it is not associated with better outcomes 2

• Inadequate follow-up - Reevaluate patients with persistent symptoms after 1 month, with earlier or more frequent evaluation for severe pain or functional deficits 2

• Neglecting lifestyle factors - Patients who modify lifestyle factors like reducing smoking and alcohol and increasing physical activity achieve better results in treatment 5

• Focusing only on pain relief - Treatment should aim to improve function and prevent disability from worsening, not just reduce pain 4

• Overlooking psychosocial factors - These are stronger predictors of outcomes than physical examination findings 2