What are the recommended treatments for back pain?

Back Pain Treatment

For acute low back pain (<4 weeks), start with reassurance about favorable prognosis, advise remaining active, and use NSAIDs or acetaminophen as first-line medication, adding superficial heat and considering spinal manipulation if needed. 1

Initial Assessment

Classify back pain into three categories:

• Nonspecific mechanical low back pain (most common)
• Pain potentially associated with radiculopathy or spinal stenosis
• Pain potentially associated with another specific spinal cause 1

Avoid routine imaging for nonspecific low back pain. 1 Only obtain MRI or CT when severe/progressive neurologic deficits are present, serious underlying conditions are suspected (red flags), or for persistent symptoms in surgical candidates. 1

Screen for psychosocial risk factors that predict progression to chronic disability, as these commonly coexist with back pain. 1

Treatment Algorithm by Duration

Acute Low Back Pain (<4 weeks)

Pharmacologic approach:

• First-line: NSAIDs (e.g., ibuprofen) or acetaminophen (up to 3000mg/day) 1
• Avoid systemic corticosteroids - they show no greater efficacy than placebo 1
• Consider short-term muscle relaxants (cyclobenzaprine 5-10mg) for muscle spasm, though evidence is limited and drowsiness is common 2

Nonpharmacologic approach:

• Superficial heat application shows good evidence for moderate benefits 1
• Spinal manipulation demonstrates small to moderate benefits 3, 1
• Advise patients to remain active and avoid bed rest 1
• Supervised exercise therapy is NOT effective for acute low back pain 3

Subacute Low Back Pain (4-12 weeks)

Continue first-line approaches if helpful, then add:

• Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention) 3, 1
• Functional restoration with cognitive-behavioral components to reduce work absenteeism 3, 1

Chronic Low Back Pain (>12 weeks)

Pharmacologic approach:

• Continue NSAIDs or acetaminophen if effective 1
• Add tricyclic antidepressants or SNRIs (duloxetine) as part of multimodal strategy 3, 1
• For radicular symptoms: Consider gabapentin (titrated to 1200-3600mg/day), though benefits are small and short-term 1, 4
• Avoid extended medication courses unless patients show continued benefits without major adverse events 3

Nonpharmacologic approach (all have moderate evidence):

• Exercise therapy - cornerstone of treatment, particularly programs with individual tailoring, supervision, stretching, and strengthening 3, 1
• Cognitive-behavioral therapy 3, 1
• Spinal manipulation 3, 1
• Massage therapy 3, 1
• Acupuncture 3, 1
• Yoga (Viniyoga-style) 3, 1
• Intensive interdisciplinary rehabilitation 3, 1

Special Considerations for Radiculopathy

For radicular pain, use a combined approach:

• NSAIDs (naproxen) target the inflammatory component 4
• Gabapentin addresses the neuropathic component 4
• Note: Lumbosacral radiculopathy is relatively refractory to existing medications 4

Avoid continuous or intermittent traction - it has not shown effectiveness for radicular symptoms 3, 1

Consider MRI and specialist referral if radicular symptoms persist beyond 4 weeks despite conservative management 1

Common Pitfalls to Avoid

Imaging overuse: MRI/CT findings are often nonspecific and do not improve outcomes in nonspecific low back pain 1

Medication misuse:

• Avoid overreliance on opioids - reserve only for time-limited courses when clearly beneficial 3
• Avoid benzodiazepines without time limitations 3
• Avoid systemic corticosteroids - they lack efficacy evidence 1

Ineffective treatments to avoid:

• Transcutaneous electrical nerve stimulation (TENS) - not proven effective 3
• Continuous or intermittent traction - not effective even with sciatica 3, 1
• Supervised exercise for acute low back pain 3

Medication Dosing Specifics

Cyclobenzaprine (if used for muscle spasm):

• Start with 5mg three times daily, may increase to 10mg three times daily 2
• Use caution in elderly - start with 5mg and titrate slowly 2
• Limit to short-term use (evidence supports 7-day courses) 2
• Combination with naproxen increases drowsiness 2

Gabapentin (for radicular pain):

• Titrate to 1200-3600mg/day 4
• Use lower starting doses and gradual titration in elderly 4
• Time-limited course recommended 4