What is the recommended first-line treatment for back pain?

First-Line Treatment for Back Pain

For acute or subacute back pain, start with nonpharmacologic treatment using superficial heat, massage, acupuncture, or spinal manipulation; if medication is needed, use NSAIDs or skeletal muscle relaxants. 1 For chronic back pain, begin with exercise therapy, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, cognitive behavioral therapy, or spinal manipulation before considering any medications. 1, 2

Acute and Subacute Low Back Pain (< 12 weeks)

Nonpharmacologic Approaches (First Priority)

• Superficial heat application provides moderate-quality evidence for pain relief and should be used as initial therapy 1, 3
• Massage therapy offers low-quality evidence but is recommended as a first-line option 1
• Acupuncture shows modest effectiveness with low-quality evidence 1
• Spinal manipulation (by appropriately trained providers) demonstrates small to moderate short-term benefits with low-quality evidence 1, 3

Patient Education and Activity

• Advise patients to remain active rather than resting in bed, as this is more effective for managing symptoms 1, 3
• Provide reassurance about favorable prognosis, as most patients improve within the first month regardless of treatment 1, 3
• Bed rest should be avoided as it can lead to deconditioning and worse outcomes 2, 3

Pharmacologic Options (If Nonpharmacologic Treatment Insufficient)

• NSAIDs are first-line medications with moderate-quality evidence for pain relief 1, 3
• Skeletal muscle relaxants (such as cyclobenzaprine, tizanidine, or metaxalone) provide moderate-quality evidence for short-term relief 1, 3
• Acetaminophen may be used but is a weaker analgesic than NSAIDs 3

What to Avoid

• Do not routinely order imaging for nonspecific low back pain, as it doesn't improve outcomes and may lead to unnecessary interventions 2, 3
• Avoid systemic corticosteroids, which have not shown greater efficacy than placebo 2, 3

Chronic Low Back Pain (> 12 weeks)

Nonpharmacologic Treatments (Mandatory First-Line)

The American College of Physicians strongly recommends starting with nonpharmacologic approaches before any medications 1:

Exercise-Based Therapies:

• Exercise therapy shows good evidence of moderate efficacy and should be a cornerstone of treatment 2, 4
• Tai chi results in moderate pain improvement 2
• Yoga (particularly Iyengar yoga) provides moderately lower pain scores and improved function 2
• Motor control exercise is recommended with low-quality evidence 1, 2

Mind-Body Interventions:

• Mindfulness-based stress reduction has moderate-quality evidence for improvements in pain and function 1, 2
• Cognitive behavioral therapy demonstrates good evidence of moderate efficacy 2, 3
• Progressive relaxation and electromyography biofeedback are recommended options 1, 2

Manual and Physical Therapies:

• Multidisciplinary rehabilitation combining physical, psychological, and educational interventions shows effectiveness, particularly when intensive 2, 3
• Acupuncture provides modest effectiveness for pain relief 2
• Massage therapy shows moderate effectiveness 2
• Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 2, 3
• Low-level laser therapy is a recommended option 1, 2

Pharmacologic Treatment Algorithm (Only After Inadequate Response to Nonpharmacologic Therapy)

Step 1: First-Line Medication

• NSAIDs should be the initial pharmacologic choice after nonpharmacologic treatments have failed 1, 2
• Assess cardiovascular and gastrointestinal risk factors before prescribing and use the lowest effective dose for the shortest duration 5

Step 2: Second-Line Medications

• Tramadol or duloxetine should be considered if NSAIDs are inadequate 1, 2, 6
• Tricyclic antidepressants (such as amitriptyline 10-25mg at bedtime) can be used as part of a multimodal strategy 2, 3

Step 3: Last Resort

• Opioids should only be considered in patients who have failed all aforementioned treatments and only if potential benefits outweigh risks after thorough discussion 1, 2

Treatment Timeline

• Continue effective nonpharmacologic treatments and add NSAIDs as first-line pharmacologic therapy if inadequate response after 4-6 weeks 2
• Consider referral for multidisciplinary rehabilitation if inadequate response after 4-6 weeks 2
• Add tramadol or duloxetine as second-line therapy if still inadequate response 2

Critical Pitfalls to Avoid

• Never recommend bed rest as it worsens outcomes and leads to deconditioning 2, 3
• Do not skip nonpharmacologic treatments and jump directly to medications for chronic pain—this violates guideline recommendations 1, 2
• Avoid routine imaging unless red flags are present (progressive neurological deficits, suspected infection, malignancy, or cauda equina syndrome) 2, 3
• Do not use systemic corticosteroids, as they lack evidence of efficacy 2, 3
• Avoid TENS therapy, which shows no difference compared to sham treatment 2
• Do not prescribe lumbar supports, as they have not shown clear benefits 2

Important Nuances

The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate (5-20 points on a 100-point scale) and generally short-term, with effects on function being smaller than effects on pain 2. However, these treatments remain first-line because they avoid medication risks and address the biopsychosocial nature of chronic pain 6, 7. The 2017 American College of Physicians guideline represents the highest-quality evidence and makes strong recommendations prioritizing nonpharmacologic approaches 1, which is reinforced by more recent evidence 2, 6.