What are the guidelines for treating back pain?

Guidelines for Treating Back Pain

The most effective approach to back pain treatment involves a stepped care model that begins with self-care, progresses to medications, and then to non-pharmacologic therapies based on pain duration and response to initial treatments. 1

Initial Assessment and Classification

• Back pain should be classified as nonspecific, potentially associated with radiculopathy/spinal stenosis, or potentially associated with another specific spinal cause, with assessment of psychosocial risk factors that predict chronic disability 1
• Diagnostic imaging should not be routinely obtained for nonspecific low back pain 1
• MRI or CT should only be performed when severe/progressive neurologic deficits are present, serious underlying conditions are suspected, or for persistent symptoms in patients who are candidates for surgery or epidural steroid injection 1

Treatment Algorithm by Pain Duration

Acute Low Back Pain (< 4 weeks)

• First-line approach:

  • Provide reassurance about favorable prognosis with high likelihood of substantial improvement within the first month 1
  • Advise patients to remain active and avoid bed rest 1
  • Provide self-care education materials based on evidence-based guidelines 1

• Pharmacologic options:

  • First-line medications: acetaminophen (up to 3000mg/day) or NSAIDs like ibuprofen 1, 2, 3
  • For muscle spasm: consider short-term muscle relaxants like cyclobenzaprine 4
  • Avoid systemic corticosteroids as they have not shown greater efficacy than placebo 1

• Non-pharmacologic options for persistent symptoms:

  • Spinal manipulation administered by providers with appropriate training 1
  • Supervised exercise therapy is not effective for acute low back pain 1

Subacute Low Back Pain (4-12 weeks)

• Continue first-line approaches from acute phase if helpful 1

• Add or modify treatment with:

  • Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention) 1
  • Functional restoration with cognitive-behavioral components to reduce work absenteeism 1

Chronic Low Back Pain (>12 weeks)

• Pharmacologic options:

  • Continue NSAIDs or acetaminophen if effective 1
  • Consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors as part of multimodal strategy 1
  • For neuropathic pain: anticonvulsants (e.g., gabapentin) may provide benefit 1
  • Extended courses of medications should be reserved for patients showing continued benefits without major adverse events 1

• Non-pharmacologic options with proven benefits:

  • Exercise therapy (programs with individual tailoring, supervision, stretching, and strengthening) 1
  • Cognitive-behavioral therapy or progressive relaxation 1
  • Spinal manipulation 1
  • Massage therapy 1
  • Acupuncture 1
  • Yoga (particularly Viniyoga-style) 1
  • Intensive interdisciplinary rehabilitation 1

Special Considerations

• For radicular symptoms:

  • Gabapentin is associated with small, short-term benefits 1
  • Avoid continuous or intermittent traction as it has not shown effectiveness 1
  • Consider MRI and specialist referral if symptoms persist beyond 4 weeks despite conservative management 1

• For patients with comorbid depression:

  • Screen and treat depression appropriately as it commonly coexists with chronic back pain 1

Common Pitfalls to Avoid

• Overuse of imaging:

  • Physicians often order imaging due to patient requests or to provide reassurance, but this doesn't improve outcomes and increases costs 1
  • Findings on MRI or CT (such as bulging discs without nerve root impingement) are often nonspecific 1

• Inappropriate activity recommendations:

  • Recommending bed rest rather than encouraging continued activity 1, 5
  • Not providing clear guidance on return to normal activities 1

• Medication misuse:

  • Overreliance on opioids which have limited evidence for long-term efficacy 1
  • Prescribing benzodiazepines without time limitations (should be time-limited if used) 1
  • Using systemic corticosteroids which lack evidence of efficacy 1

• Barriers to effective care:

  • Limited access to adjunct services like physical therapy can prevent appropriate referrals 1
  • Insufficient time for patient education about why imaging is not needed 1

• Treatment persistence:

  • Abandoning treatment approaches too quickly - improvements in function and pain may take time, particularly with exercise-based interventions 6, 7