What are the treatment options for back pain?

Treatment Options for Back Pain

For most patients with back pain, first-line treatment should include non-pharmacological self-care measures and acetaminophen or NSAIDs, with additional therapies added based on pain duration, severity, and response to initial treatment. 1, 2

Initial Management for Acute Back Pain (<4 weeks)

• Self-care measures should be recommended as first-line treatment, including remaining active rather than resting in bed and applying heat via heating pads or heated blankets for short-term relief 1, 2
• Acetaminophen should be considered as a first-line medication due to its favorable safety profile, though recent evidence suggests it may be less effective than previously thought for acute low back pain 1
• NSAIDs are more effective than acetaminophen for pain relief but carry gastrointestinal, renovascular, and cardiovascular risks that should be carefully assessed before prescribing 1
• Skeletal muscle relaxants such as cyclobenzaprine can be effective for short-term pain relief in acute back pain but cause sedation and should only be used for short periods (up to 2-3 weeks) 1, 3
• For severe acute pain not responding to acetaminophen or NSAIDs, skeletal muscle relaxants may be added as adjunctive therapy 1, 3

Management for Subacute Back Pain (4-12 weeks)

• Continue self-care measures and first-line medications (acetaminophen or NSAIDs) if providing benefit 1
• Consider spinal manipulation administered by providers with appropriate training, which shows small to moderate short-term benefits 1, 4
• Brief individualized educational interventions can reduce sick leave in workers with subacute back pain 1, 4
• If pain persists despite these measures, consider intensive interdisciplinary rehabilitation 1, 4

Management for Chronic Back Pain (>12 weeks)

• Non-pharmacological therapies with proven benefits should be considered, including:
  • Exercise therapy with individual tailoring, supervision, stretching, and strengthening 1, 4
  • Yoga, acupuncture, massage therapy, or spinal manipulation 1, 4
  • Cognitive-behavioral therapy or progressive relaxation 1, 4
• For pharmacological management:
  • NSAIDs remain a first-line option but have smaller benefits for chronic back pain than previously observed 1
  • Duloxetine has been found effective for chronic low back pain and can be considered as a second-line option 1
  • Tramadol may be considered as a second-line therapy if NSAIDs are ineffective 1, 5
  • Opioids should only be considered if other treatments have failed and only if potential benefits outweigh risks, with careful discussion of known risks and realistic benefits 1, 6

Special Considerations

• Medium-firm mattresses are preferred over firm mattresses for patients with chronic back pain 1, 2
• For elderly patients, acetaminophen is the safest first-line medication option, with NSAIDs used at the lowest effective dose for the shortest period necessary due to increased risks 2, 6
• Benzodiazepines have been found ineffective for radicular back pain and should be avoided 1
• Systemic corticosteroids do not appear to be effective for back pain and are not recommended 1

Common Pitfalls to Avoid

• Prolonged bed rest should be avoided as it can lead to deconditioning and potentially worsen symptoms 1, 4
• Routine imaging for initial evaluation should not be performed unless there are red flags suggesting serious underlying conditions 1
• Extended courses of medications should generally be reserved for patients clearly showing continued benefits without major adverse events 1, 3
• Overreliance on muscle relaxants can lead to sedation and falls risk, particularly in elderly patients 2, 3
• Recent evidence suggests acetaminophen may be ineffective for acute low back pain, so NSAIDs may be preferred if there are no contraindications 1, 7