What is the best course of treatment for persistent left lower back pain?

Treatment of Persistent Left Lower Back Pain

For persistent (chronic) left lower back pain, initiate NSAIDs or acetaminophen as first-line pharmacologic therapy while simultaneously implementing evidence-based nonpharmacologic treatments including exercise therapy, cognitive-behavioral therapy, or spinal manipulation. 1, 2

Initial Pharmacologic Management

• NSAIDs are the preferred first-line medication, providing small to moderate improvements in pain intensity 3, 2
• Prescribe at the lowest effective doses for the shortest necessary duration, assessing cardiovascular and gastrointestinal risk factors before initiating therapy 3
• Acetaminophen (up to 3000mg/day) serves as an alternative first-line option due to favorable safety profile, though efficacy data are limited 3, 2
• Most NSAIDs show equivalent efficacy in head-to-head trials, so selection should be based on cost, availability, and individual patient factors 3

Core Nonpharmacologic Interventions (Moderately Effective)

The following therapies have fair to good evidence for chronic low back pain and should be offered based on patient preference and availability:

• Exercise therapy is a cornerstone treatment, with programs incorporating individual tailoring, supervision, stretching, and strengthening showing the best outcomes 1, 2
• Cognitive-behavioral therapy or progressive relaxation demonstrates moderate efficacy for pain and function 1, 2
• Spinal manipulation (by chiropractors or other appropriately trained providers) provides moderate effectiveness regardless of manipulator profession 1, 2
• Acupuncture shows moderate effectiveness with fair to good supporting evidence 1, 2
• Massage therapy provides moderate short-term benefits 1, 2
• Viniyoga-style yoga demonstrates moderate efficacy 1
• Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational interventions) is moderately effective, though may not be available in all settings 1, 2

Second-Line Pharmacologic Options

If first-line medications provide inadequate relief:

• Tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (like duloxetine) can be added as part of multimodal strategy 2, 4
• Gabapentin may be considered specifically for radicular symptoms 2
• Tramadol or opioid analgesics should only be considered for severe, disabling pain uncontrolled with NSAIDs/acetaminophen, weighing substantial risks including aberrant drug-related behaviors, abuse potential, and addiction 3

Critical Advice for Patients

• Advise patients to remain active and avoid bed rest, as activity restriction prolongs recovery 1, 3, 2
• Provide evidence-based information about expected course and effective self-care options 1
• Patient expectations of benefit from treatment should guide intervention selection, as expectations influence outcomes 1

When to Consider Imaging and Specialist Referral

• Do NOT routinely obtain imaging for nonspecific low back pain, as it provides no clinical benefit and can lead to increased healthcare utilization 1, 2
• Obtain MRI (preferred) or CT only if the patient is a surgical or interventional candidate after 6 weeks of optimal conservative management 1, 2
• Consider specialist consultation when patients do not respond to standard noninvasive therapies, though optimal timing is not well-defined 1
• Perform immediate imaging only if severe/progressive neurologic deficits, cauda equina syndrome, or serious underlying conditions (cancer, infection, fracture) are suspected 1, 2

Treatments to AVOID

• Systemic corticosteroids are NOT recommended, as they show no greater efficacy than placebo 3, 2
• Continuous or intermittent traction is NOT effective for chronic low back pain with or without sciatica 1, 2
• Transcutaneous electrical nerve stimulation (TENS) has not been proven effective 1
• Insufficient evidence exists for interferential therapy, low-level laser therapy, shortwave diathermy, or ultrasonography 1

Common Pitfalls

• Do not prescribe extended medication courses without clear evidence of continued benefits and absence of major adverse events 3
• Monitor for hepatotoxicity when using maximum-dose acetaminophen, especially in elderly or hepatically impaired patients 3
• Screen and treat coexisting depression appropriately, as it commonly accompanies chronic back pain 2
• Recognize that many MRI abnormalities appear in asymptomatic individuals and imaging findings correlate poorly with symptoms 1, 2