What are the medical management options for chronic low back pain (LBP) in older adults?

Medical Management of Chronic Low Back Pain in Older Adults

For older adults with chronic low back pain, begin with acetaminophen or NSAIDs as first-line pharmacological therapy, combined with exercise therapy and patient education to remain active, while strongly avoiding interventional procedures such as epidural injections and radiofrequency ablation which lack evidence of benefit. 1, 2

First-Line Pharmacological Management

Initial Medication Selection

• Acetaminophen (up to 3000 mg/day) represents the safest first-line option, particularly in older adults, due to its favorable safety profile despite being slightly less effective than NSAIDs for pain relief 1, 2, 3
• NSAIDs (such as naproxen or ibuprofen) provide superior pain relief compared to acetaminophen but require careful risk assessment in older adults 1, 2, 4
• Before prescribing NSAIDs in older adults, assess cardiovascular risk factors, gastrointestinal bleeding risk, and renal function, using the lowest effective dose for the shortest duration 1, 5, 3
• NSAIDs carry increased risks of ulcers, bleeding, cardiovascular events, and renal toxicity, with risk escalating with longer use, older age, concurrent corticosteroid or anticoagulant use, smoking, and alcohol consumption 3

Critical Safety Considerations for Older Adults

• Monitor for asymptomatic liver enzyme elevations when using acetaminophen at higher doses (approaching 4 g/day) 5
• Avoid systemic corticosteroids entirely as they show no greater efficacy than placebo 1, 2, 5
• Ensure NSAIDs are prescribed at adequate therapeutic doses before declaring treatment failure 6

First-Line Non-Pharmacological Management

Patient Education and Activity Modification

• Provide evidence-based reassurance that chronic low back pain typically improves with activity rather than rest, emphasizing the importance of remaining active and avoiding bed rest 1, 2
• Educate patients using evidence-based materials about the favorable natural history of low back pain and effective self-care strategies 1, 2

Exercise Therapy as Cornerstone Treatment

• Exercise therapy demonstrates moderate efficacy and should be the cornerstone of non-pharmacological treatment for chronic low back pain in older adults 1, 2, 7
• Exercise programs should include individual tailoring, supervision, stretching, and strengthening components 1, 5, 7
• Low-quality evidence suggests that physical therapy modalities in older adults (≥65 years) are associated with small-to-moderate pain reduction and small functional improvements 8
• No single exercise type has proven superior to others; participation can occur in group or individual settings 7, 9

Second-Line Treatment Options

Additional Pharmacological Agents

• Duloxetine (starting at 30 mg daily, titrating to 60 mg daily) represents the preferred second-line agent when first-line therapy provides inadequate response 6, 4
• Tricyclic antidepressants may provide pain relief in patients without contraindications, though older adults require particular caution due to anticholinergic effects 1, 2, 5
• Tramadol represents a reasonable second-line option if duloxetine and NSAIDs are contraindicated or ineffective 6
• Gabapentin shows only small, short-term benefits and should be reserved for patients with radicular symptoms 1, 5
• Skeletal muscle relaxants (cyclobenzaprine, tizanidine, metaxalone) may provide short-term relief when muscle spasm contributes to pain 1, 5

Additional Non-Pharmacological Therapies

• Cognitive-behavioral therapy demonstrates moderate efficacy for chronic low back pain and should be considered when pain persists 1, 2, 7
• Spinal manipulation shows moderate effectiveness for pain relief and functional improvement in chronic low back pain 1, 2, 5
• Acupuncture, massage therapy, yoga, tai chi, and mindfulness-based stress reduction all show evidence of effectiveness with small to moderate benefits 1, 2, 6
• Intensive interdisciplinary rehabilitation (combining physical, psychological, and educational interventions) shows good evidence of effectiveness for chronic low back pain 1, 2, 9

Interventional Procedures: Strong Recommendations Against

Evidence-Based Avoidance

• The 2025 BMJ guideline issues strong recommendations AGAINST the following interventional procedures for chronic axial spine pain: 1
  • Joint radiofrequency ablation with or without joint-targeted injection
  • Epidural injection of local anesthetic, steroids, or their combination
  • Joint-targeted injection of local anesthetic, steroids, or their combination
  • Intramuscular injection of local anesthetic with or without steroids
• For chronic radicular spine pain, strong recommendations AGAINST: 1
  • Dorsal root ganglion radiofrequency ablation
  • Epidural injection of local anesthetic, steroids, or their combination
• These recommendations represent the most recent (2025) high-quality evidence and supersede older recommendations that suggested considering these procedures 1

When to Escalate Care

Indications for Specialist Referral

• Refer to multidisciplinary pain management when pain persists despite optimized pharmacologic and non-pharmacologic therapy 6
• Consider referral when significant functional disability interferes with work or daily activities 6
• Immediate imaging and specialist consultation required for red flags: progressive neurological deficits, cauda equina syndrome (medical emergency), suspected infection, or malignancy 1, 2, 5

Opioid Consideration (Last Resort)

• Opioids should only be considered after documented failure of all other therapies, and only when potential benefits clearly outweigh risks 6
• Conduct thorough risk assessment including screening for substance use disorder, mental health conditions, and concurrent sedative use before initiating opioid therapy 6
• Extended medication courses should be reserved for patients clearly showing continued benefits without major adverse events 1, 5

Common Pitfalls to Avoid in Older Adults

• Do not routinely obtain imaging for nonspecific chronic low back pain as findings are often nonspecific and do not improve outcomes 1, 2, 5
• Avoid prolonged bed rest as it leads to deconditioning and potentially worsens symptoms 1, 5
• Do not rely on passive therapies (rest, medications alone) as they are associated with worsening disability 7, 9
• Avoid overreliance on imaging findings without clinical correlation, as bulging discs without nerve root impingement are often nonspecific 5
• Most passive physical therapies (interferential therapy, short-wave diathermy, traction, ultrasound, electrical muscle stimulation) lack evidence of effectiveness and should be avoided 1
• Screen for and treat coexisting depression as it commonly accompanies chronic back pain and predicts worse outcomes 2

Treatment Algorithm Summary

Step 1: Acetaminophen or NSAIDs (with appropriate safety monitoring) + exercise therapy + education to remain active 1, 2, 7

Step 2: Add duloxetine if inadequate response; consider cognitive-behavioral therapy, spinal manipulation, or other evidence-based non-pharmacological therapies 1, 2, 6

Step 3: Consider intensive interdisciplinary rehabilitation program combining physical, psychological, and educational interventions 1, 2, 9

Step 4: Multidisciplinary pain specialist referral for persistent symptoms despite optimized therapy 6

Avoid entirely: Interventional procedures (epidural injections, radiofrequency ablation, facet injections), systemic corticosteroids, prolonged bed rest, and passive therapies 1, 2