What are the treatment options for back pain?

Treatment Options for Back Pain

The initial management of back pain should focus on non-pharmacological interventions, including physical therapy with eccentric strengthening exercises and patient education, which have shown good efficacy with 75% of patients experiencing significant improvement within 48 hours. 1

Non-Pharmacological Treatment Options (First-Line)

Physical Activity and Exercise

• Avoid bed rest completely - this worsens outcomes 2
• Regular physical activity with gradual return to normal activities 1
• Exercise therapy tailored to the specific condition:
  • Eccentric strengthening exercises
  • Walking programs
  • Core strengthening
  • Yoga or tai chi 3

Physical Therapy Interventions

• Manual therapy techniques
• Heat application for pain relief
• Patient education on proper body mechanics
• Supervised exercise programs 1, 3

Risk Stratification

The STarT Back tool can help identify appropriate treatment intensity 1:

• Low risk patients: Self-management strategies
• Medium risk patients: Physiotherapy with patient-centered plan
• High risk patients: Comprehensive biopsychosocial assessment

Pharmacological Treatment Options (Second-Line)

NSAIDs

• First-line pharmacological treatment for back pain 1
• 75% of patients show good or very good response within 48 hours
• Consider continuous rather than intermittent use in active disease
• COX-2 selective NSAIDs may be preferred for long-term treatment due to fewer gastric side effects 1

Muscle Relaxants

• Cyclobenzaprine may be used as an adjunct for acute, painful musculoskeletal conditions with muscle spasm 4
• Important dosing considerations:
  • Use only for short periods (up to 2-3 weeks)
  • Start with 5mg in elderly patients or those with mild hepatic impairment
  • Not recommended for moderate to severe hepatic impairment 4
  • Common side effects include drowsiness and dry mouth

Other Medications

• Duloxetine may be beneficial for chronic back pain 2
• Evidence is inconclusive for benzodiazepines, antidepressants, corticosteroids, anticonvulsants, cannabis, and acetaminophen 2
• Opioids should be used at the lowest possible dose and reevaluated regularly, as efficacy for low back pain with radicular symptoms is inconclusive 1

Interventional Procedures

Injections

• Epidural steroid injections may provide short-term symptom relief in patients with radicular pain, but are not recommended for non-radicular back pain 2

Surgical Considerations

• Surgery should be considered only after failure of conservative management (typically after 3 months) 1
• Appropriate surgical candidates include:
  • Patients with persistent functional disabilities
  • Progressive spinal stenosis
  • Worsening spondylolisthesis
  • Herniated disk with persistent neurological deficits 2
• Lumbar discectomy is the established procedure for nerve compression when conservative management fails 1
• Fusion should only be considered in specific circumstances:
  • Recurrent disc herniations with evidence of instability
  • Chronic axial low back pain with radiographic evidence of instability
  • Manual laborers with severe degenerative changes 1

Diagnostic Imaging

• Routine imaging for acute back pain (<4 weeks) without red flags provides no clinical benefit 1
• Imaging is indicated when:
  • Red flags are present (cauda equina syndrome, progressive neurological deficits)
  • Pain persists despite conservative therapy (>3 months)
  • Neuromuscular deficits are present 2
• MRI is recommended if symptoms persist despite conservative management 1

Special Considerations

When to Refer

• Refer to pain management if symptoms persist after standard therapies (3 months)
• Immediate specialist evaluation for patients with:
  • Severe neurological deficits
  • Cauda equina syndrome
  • Progressive neurological deterioration 1

Common Pitfalls to Avoid

1. Prescribing bed rest (worsens outcomes)
2. Ordering unnecessary imaging for acute back pain without red flags
3. Prolonged use of muscle relaxants beyond 2-3 weeks
4. Relying solely on passive treatments
5. Initiating opioids before exhausting other options
6. Delaying active rehabilitation strategies

The most effective approach to back pain combines early activity, appropriate non-pharmacological interventions, judicious use of medications when needed, and consideration of interventional or surgical options only for specific indications after conservative measures have failed.