Treatment of Back Pain
For back pain, start with NSAIDs (ibuprofen 400mg every 4-6 hours) combined with exercise therapy and remaining active, avoiding bed rest entirely. 1, 2
Initial Assessment
Classify the back pain into one of three categories 1:
- Nonspecific mechanical low back pain (most common)
- Pain with radiculopathy or spinal stenosis (leg symptoms, neurologic findings)
- Pain from specific spinal pathology (red flags present)
Red flags requiring immediate evaluation include progressive motor/sensory loss, new urinary retention, history of cancer, recent spinal procedure, or significant trauma. 3, 4 Only obtain imaging (MRI or CT) when red flags are present, severe neurologic deficits exist, or symptoms persist despite conservative treatment in surgical candidates. 1
Do not routinely order imaging for nonspecific low back pain - findings are often nonspecific and do not improve outcomes. 5, 1
Treatment Algorithm by Duration
Acute Back Pain (< 4 weeks)
First-line approach 1:
- Provide reassurance about favorable prognosis (substantial improvement expected within first month)
- Advise remaining active and avoiding bed rest
- Start ibuprofen 400mg every 4-6 hours (up to 3200mg daily maximum) or acetaminophen up to 3000mg daily 1, 2
- Apply superficial heat 1
- Consider spinal manipulation 1
Avoid systemic corticosteroids - they show no benefit over placebo. 1
Subacute Back Pain (4-12 weeks)
Continue effective acute treatments and add 1:
- Intensive interdisciplinary rehabilitation with cognitive-behavioral components if not improving
- Structured exercise therapy with supervision, stretching, and strengthening 6
Chronic Back Pain (>12 weeks)
Non-pharmacologic treatments (first-line) 1, 3:
- Exercise therapy (cornerstone of treatment - no single type superior to another)
- Cognitive-behavioral therapy
- Spinal manipulation
- Massage therapy
- Acupuncture
- Yoga
Pharmacologic options (second-line) 1, 3:
- Continue NSAIDs or acetaminophen if effective
- Add duloxetine for neuropathic component 6, 3
- Consider tricyclic antidepressants or SNRIs as part of multimodal strategy 1
- Gabapentin for radicular symptoms 1
Interventional Procedures: Strong Recommendations AGAINST
The 2025 BMJ guidelines strongly recommend against the following interventional procedures for chronic axial (non-radicular) back pain 5:
- Epidural steroid injections
- Facet joint injections
- Radiofrequency ablation
- Intramuscular trigger point injections
These procedures do not improve morbidity, mortality, or quality of life. 5, 7
Exception: For sacroiliac joint dysfunction specifically, sacroiliac joint injection and denervation/ablation receive strong recommendations. 5 For facet-mediated pain with positive diagnostic blocks, radiofrequency ablation may be considered only after failed conservative treatment. 5
For radicular pain: Epidural steroid injections may provide short-term relief but are not recommended for long-term management. 5, 3 Consider MRI and specialist referral if radicular symptoms persist beyond 4 weeks despite conservative management. 1
Critical Pitfalls to Avoid
- Never recommend bed rest - it worsens disability and outcomes 1, 8
- Avoid overuse of imaging - MRI findings often don't correlate with symptoms 1
- Don't prescribe opioids long-term - evidence is inconclusive for chronic use 3
- Screen for depression - it commonly coexists and requires treatment 1
- Avoid passive treatments - active strategies like exercise decrease disability while passive approaches worsen it 8, 9
Special Considerations
Yellow flags (psychosocial risk factors for chronicity) should be identified early, including psychological distress, fear-avoidance beliefs, and work-related factors. 3 Address these with cognitive-behavioral interventions to prevent progression to chronic pain. 1, 3
Keep patients active despite pain - this is the most important evidence-based message. 8 The smallest effective dose of medication should be used, with focus on functional restoration rather than complete pain elimination. 2, 9