What are the recommended treatment options for chronic back pain?

Treatment Options for Chronic Low Back Pain

For patients with chronic low back pain, nonpharmacologic treatments should be the initial approach, including exercise therapy, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. 1

First-Line Nonpharmacologic Treatments

• Exercise therapy shows good evidence of moderate efficacy and should be a cornerstone of treatment for chronic low back pain 2
• Multidisciplinary rehabilitation combining physical, psychological, and educational interventions demonstrates effectiveness, particularly when intensive 1
• Acupuncture provides modest effectiveness for pain relief 1
• Mindfulness-based stress reduction shows moderate-quality evidence for improvements in pain and function 1, 2
• Cognitive behavioral therapy demonstrates good evidence of moderate efficacy 2
• Tai chi results in moderate pain improvement compared with wait-list controls 1
• Yoga (particularly Iyengar yoga) results in moderately lower pain scores and improved function compared with usual care 1
• Massage therapy shows moderate effectiveness for chronic low back pain 2
• Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 2

Second-Line Pharmacologic Treatments

For patients who have had an inadequate response to nonpharmacologic therapy, consider the following pharmacologic options:

• NSAIDs should be used as first-line pharmacologic therapy 1
• Tramadol or duloxetine should be considered as second-line therapy 1
• Tricyclic antidepressants (such as amitriptyline) and serotonin-norepinephrine reuptake inhibitors should be used as part of a multimodal strategy 1, 3
• Opioids should only be considered as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks 1

Treatment Algorithm

1. Begin with nonpharmacologic approaches:

   • Prescribe a structured exercise program tailored to patient capabilities 1, 2
   • Consider adding complementary approaches based on patient preference (yoga, mindfulness, tai chi) 1, 2
   • Implement cognitive-behavioral therapy to address psychosocial factors 1, 2

2. If inadequate response after 4-6 weeks:

   • Continue effective nonpharmacologic treatments
   • Add NSAIDs as first-line pharmacologic therapy 1
   • Consider referral for multidisciplinary rehabilitation 1

3. If still inadequate response:

   • Add tramadol or duloxetine as second-line pharmacologic therapy 1
   • Consider tricyclic antidepressants (starting with low doses, e.g., amitriptyline 10-25mg at bedtime) 1, 3

4. For persistent severe pain despite above measures:

   • Consider opioids only after thorough discussion of risks and benefits 1
   • Implement close monitoring for efficacy and adverse effects 1

Important Considerations and Pitfalls

• Avoid routine imaging for nonspecific low back pain as it does not improve outcomes and may lead to unnecessary interventions 2, 4
• Bed rest is contraindicated and can worsen outcomes 2, 5
• The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate (5-20 points on a 100-point scale) and generally short-term 1
• Effects on function are generally smaller than effects on pain 1
• Multidisciplinary approaches that address both physical and psychosocial factors show better outcomes than single-modality treatments 6
• Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS for pain intensity or function 5
• Lumbar supports have not shown clear benefits for chronic back pain 5
• Systemic corticosteroids have not shown greater efficacy than placebo 2

Special Populations

• For elderly patients, lower medication dosages are recommended (e.g., amitriptyline 10mg three times daily with 20mg at bedtime) 3
• For patients with radicular symptoms, evidence for nonpharmacologic therapies is very limited 1
• Patients with significant psychological factors, secondary gain, or personality disorders may have poorer outcomes and require more intensive psychological intervention 6

By implementing this evidence-based approach to chronic low back pain management, clinicians can help improve pain, function, and quality of life for their patients while minimizing risks associated with pharmacologic treatments.