What is the best course of treatment for a patient with low back pain and stiffness on the right side that improves with movement, 8 months after an injury has healed?

Treatment of Chronic Unilateral Low Back Pain with Movement-Responsive Stiffness

Start with NSAIDs at the lowest effective dose combined with an individualized, supervised exercise program focusing on stretching and strengthening—this combination addresses both pain and the underlying movement dysfunction that characterizes your patient's presentation. 1, 2

Understanding the Clinical Picture

Your patient's presentation—pain and stiffness that improves with movement 8 months post-injury—strongly suggests chronic nonspecific low back pain with mechanical features rather than inflammatory or neuropathic pathology. 2, 3 The improvement with movement is a favorable prognostic sign indicating that activity-based interventions will be particularly effective. 1, 2

First-Line Treatment Approach

Pharmacologic Management

• NSAIDs (ibuprofen or naproxen) are the most effective oral medication option, providing moderate pain relief superior to acetaminophen and other pharmacologic alternatives. 1, 2
• Prescribe at the lowest effective dose for the shortest necessary duration to minimize gastrointestinal and cardiovascular risks. 1
• If NSAIDs are contraindicated, acetaminophen (maximum 4g/day) is an acceptable alternative, though evidence shows minimal benefit over placebo in acute pain and its efficacy in chronic pain is limited. 1

Nonpharmacologic Management (Primary Treatment)

• Exercise therapy is the cornerstone of treatment for chronic low back pain, with moderate-quality evidence showing approximately 10-point improvement on a 100-point pain scale and sustained functional benefits. 2
• The exercise program must be individualized and supervised, incorporating both stretching and strengthening components tailored to the patient's specific movement impairments. 2
• Advise the patient to remain active and explicitly avoid bed rest, as activity promotes recovery while rest leads to deconditioning and symptom perpetuation. 1, 2
• Yoga (specifically Viniyoga or Iyengar styles) demonstrates moderate superiority over self-care education with sustained benefits at 26 weeks and decreased medication use. 2
• Tai chi has moderate-quality evidence supporting its effectiveness for chronic low back pain. 2

Additional Nonpharmacologic Options

• Spinal manipulation by appropriately trained providers can provide small to moderate short-term benefits and is a guideline-recommended option. 1, 2
• Superficial heat application provides moderate benefits and can be used as an adjunct for symptom relief. 4
• Motor control exercises have moderate-quality evidence supporting their effectiveness, particularly for patients with movement-responsive pain patterns like your patient. 2

Second-Line Treatment Options

If Initial Therapy Insufficient After 4-6 Weeks

• Duloxetine (30-60 mg daily) is specifically recommended as second-line pharmacologic therapy, particularly if there is any neuropathic component to the pain. 2
• Tramadol is an alternative second-line medication option. 2
• Cognitive-behavioral therapy or mindfulness-based stress reduction should be considered if psychological factors are present (fear-avoidance behaviors, catastrophizing, depression), with moderate-quality evidence for chronic low back pain. 2
• Massage therapy and acupuncture have evidence supporting their use in chronic low back pain, though benefits are typically small to moderate and short-term. 4

Critical Pitfalls to Avoid

• Do NOT order routine imaging unless red flags are present (progressive neurological deficits, cauda equina symptoms, suspected infection/malignancy, or significant trauma). 5, 2
• Do NOT perform interventional procedures such as epidural injections, facet joint injections, or radiofrequency ablation for axial (non-radicular) low back pain—these do not improve morbidity or quality of life. 2
• Do NOT prescribe opioids unless all above treatments have been documented to fail and benefits clearly outweigh risks after thorough discussion with the patient. 2
• Do NOT use systemic corticosteroids—they have not shown greater efficacy than placebo for low back pain. 4

When to Refer

• Refer to multidisciplinary pain management if pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months. 2
• Immediate specialist consultation is required only for red flags: progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy. 2

Expected Outcomes and Follow-Up

• Most patients with chronic low back pain show improvement within 4-6 weeks of appropriate treatment, though up to one-third may have persistent moderate pain at one year. 1
• Reassess at 4-6 weeks to evaluate treatment response and modify the plan as needed. 5
• The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate and generally short-term, but effects are cumulative when multiple modalities are combined. 4