What is the recommended treatment for back pain?

Treatment Prescription for Back Pain

Initial Assessment and Classification

Start by determining the duration and type of back pain to guide treatment selection: acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks), and whether radicular symptoms are present. 1

Red Flags to Screen For

• Cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia)
• Progressive neurological deficits
• Suspected fracture, infection, or malignancy
• Imaging is NOT routinely needed unless red flags present or no improvement after 6 weeks 2, 3

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First-Line Treatment: Non-Pharmacologic Approaches

For Acute Low Back Pain (<4 weeks)

Advise patients to remain active and continue ordinary activities within pain limits—bed rest should be avoided. 4, 2, 3

• Heat therapy: Apply heating pads or heated blankets for short-term relief 4, 2
• Spinal manipulation: Small to moderate short-term benefits when administered by trained providers 1
• Activity modification: Return to work early is associated with less disability 3
• Exercise therapy is NOT effective for acute pain; wait 2-6 weeks before starting 1

For Subacute Low Back Pain (4-12 weeks)

• Intensive interdisciplinary rehabilitation: Moderately effective, includes physician consultation coordinated with psychological, physical therapy, social, or vocational interventions 1
• Functional restoration with cognitive-behavioral component: Reduces work absenteeism 1

For Chronic Low Back Pain (>12 weeks)

Multiple nonpharmacologic therapies show moderate effectiveness and should be prioritized over medications: 1

• Exercise therapy: Programs with individual tailoring, supervision, stretching, and strengthening show best outcomes 1
• Acupuncture: Moderate effectiveness 1
• Massage therapy: Moderate effectiveness 1
• Yoga (Viniyoga-style): Moderate effectiveness 1
• Cognitive-behavioral therapy or progressive relaxation: Moderate effectiveness 1
• Spinal manipulation: Moderate effectiveness 1

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Second-Line Treatment: Pharmacologic Management

For Acute and Chronic Non-Radicular Back Pain

Start with acetaminophen or NSAIDs as first-line medication, with acetaminophen preferred in elderly patients due to superior safety profile. 4, 2

Acetaminophen

• Dose: Up to 4g/24 hours from all sources 4
• Favorable safety profile, especially in elderly 4
• Monitor for hepatotoxicity at maximum doses 4

NSAIDs (Ibuprofen, Naproxen)

• Ibuprofen dose: 400mg every 4-6 hours as needed, not to exceed 3200mg/day 5
• Naproxen: Preferred for radiculopathy due to moderate efficacy 6
• Small improvement in pain intensity (mean difference -3.30 on 0-100 VAS scale) 7
• Use lowest effective dose for shortest duration 4, 5
• Caution in elderly: Assess cardiovascular, renal, and gastrointestinal risk factors before prescribing 4
• Increased risks of GI bleeding, renovascular complications, and MI in elderly 4

Skeletal Muscle Relaxants (if pain persists)

• Cyclobenzaprine: Improved short-term pain relief after 2-7 days 2
• Dose: Start with 5mg and titrate slowly, especially in hepatic impairment 8
• More drowsiness than NSAIDs; combination with naproxen increases side effects 8
• Time-limited course recommended 1

For Radicular Pain/Sciatica

Combine NSAIDs (targeting inflammation) with gabapentin (targeting neuropathic component) for radicular symptoms. 6

Gabapentin

• Dose: Titrate up to 1200-3600mg/day 6
• Small, short-term benefits in radiculopathy 1, 6
• Lower starting doses and gradual titration reduce adverse effects in elderly 6
• Not FDA-approved for low back pain; use time-limited course 1, 6

Third-Line Options (Severe, Disabling Pain Only)

Reserve opioids or tramadol for severe, disabling pain uncontrolled by acetaminophen and NSAIDs, after carefully weighing substantial risks including abuse potential. 4, 2

Tramadol

• Initial dose: 50-100mg every 4-6 hours, not exceeding 400mg/day 9
• Elderly >75 years: Do not exceed 300mg/day 9
• Renal impairment (CrCl <30): Increase dosing interval to 12 hours, max 200mg/day 9
• Prescribe only for breakthrough pain, shortest period, lowest effective dose 4

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Medications NOT Recommended

• Systemic corticosteroids: Not more effective than placebo for low back pain with or without sciatica 1, 2
• Benzodiazepines: Similar efficacy to muscle relaxants but higher risk of abuse, addiction, tolerance 1
• Long-term opioids: Insufficient evidence for chronic use 10
• Epidural corticosteroid injections: Not recommended except for short-term relief in radicular pain 10

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Special Populations

Elderly Patients

• First choice: Acetaminophen up to 4g/24 hours 4
• Second choice: NSAIDs at lowest dose for shortest duration, after assessing CV/GI/renal risk 4
• Aging affects drug metabolism; elderly more susceptible to anticholinergic effects (confusion, constipation) 4
• Tramadol max 300mg/day if >75 years old 9

Hepatic Impairment

• Cyclobenzaprine: Start 5mg and titrate slowly in mild impairment; not recommended in moderate-severe impairment 8

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Duration and Monitoring

Extended medication courses should be reserved for patients showing continued benefits without major adverse events. 1, 6

• Most acute episodes resolve within 6 weeks regardless of treatment 3
• Reassess at 6 weeks; consider imaging if no improvement 2, 3
• Monitor for medication-specific adverse effects (hepatotoxicity with acetaminophen, GI/CV/renal with NSAIDs, sedation/falls with muscle relaxants) 4

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Common Pitfalls to Avoid

• Do not prescribe bed rest: Staying active improves outcomes 4, 2, 3
• Do not order routine imaging: Only indicated with red flags, neurological deficits, or failure to improve after 6 weeks 2, 3
• Do not use firm mattresses: Medium-firm mattresses are preferable 4, 2
• Do not combine multiple sedating medications: Increases fall risk, especially in elderly 4
• Do not use traction: Not effective for sciatica or chronic low back pain 1