Treatment of Back Pain
For acute back pain, start with NSAIDs and advise the patient to remain active while avoiding bed rest; for chronic back pain, begin with nonpharmacologic therapies such as exercise, spinal manipulation, or cognitive-behavioral therapy before considering medications. 1
Acute Back Pain (<4 weeks)
First-Line Treatment
- NSAIDs are the preferred initial medication, providing small to moderate pain relief superior to placebo and should be prescribed at the lowest effective dose for the shortest duration necessary. 1, 2
- Acetaminophen is an acceptable alternative for patients with NSAID contraindications, though evidence shows no significant difference from placebo for pain intensity or function in acute low back pain. 1, 2
- Advise patients to remain active and continue ordinary activities within pain limits—bed rest prolongs recovery and delays return to normal function. 1, 2
- Apply superficial heat via heating pads or heated blankets for short-term symptomatic relief. 2, 3
Second-Line Pharmacologic Options
- Skeletal muscle relaxants improve short-term pain relief after 2-7 days compared to placebo, but all are associated with central nervous system adverse effects, primarily sedation. 1, 2
- No compelling evidence exists that different skeletal muscle relaxants differ in efficacy, though cyclobenzaprine should be initiated at 5 mg in elderly patients and titrated slowly upward. 4
- Reserve opioids only for severe, disabling pain uncontrolled by NSAIDs and acetaminophen, given substantial risks of abuse, addiction, and aberrant drug-related behaviors. 1, 2
Nonpharmacologic Interventions
- Spinal manipulation by appropriately trained providers provides small to moderate short-term benefits for acute low back pain. 1, 2
- Supervised exercise therapy and home exercise regimens are not effective for acute low back pain. 1
Treatments NOT Recommended
- Do not prescribe systemic corticosteroids—they have not been shown more effective than placebo for acute low back pain with or without sciatica. 1, 2, 3
- Benzodiazepines show similar effectiveness to skeletal muscle relaxants but carry risks for abuse, addiction, and tolerance; if used, only prescribe time-limited courses. 2
- Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute low back pain. 2
Subacute Back Pain (4-12 weeks)
Treatment Approach
- Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention) is moderately effective for subacute low back pain. 1
- Functional restoration with a cognitive-behavioral component reduces work absenteeism in occupational settings. 1
- Many trials enrolled mixed populations with chronic and subacute symptoms, suggesting that chronic pain treatments may reasonably be applied to subacute situations. 1
Chronic Back Pain (>12 weeks)
First-Line: Nonpharmacologic Therapies
Nonpharmacologic treatment is first-line management for chronic low back pain. 1, 5
- Exercise therapy (incorporating individual tailoring, supervision, stretching, and strengthening) shows moderate effectiveness. 1
- Spinal manipulation provides small to moderate benefits, with no evidence that benefits vary by profession of manipulator (chiropractor vs. other trained clinician). 1
- Cognitive-behavioral therapy, biofeedback, and relaxation training provide relief for assessment periods ranging from 4 weeks to 2 years. 1
- Acupuncture, massage therapy, and Viniyoga-style yoga show moderate effectiveness. 1
- Intensive interdisciplinary rehabilitation is moderately effective for chronic low back pain. 1
- Physical or restorative therapy (physiotherapy, fitness classes, exercise therapy) provides effective relief for periods ranging from 2 to 18 months. 1
Second-Line: Pharmacologic Therapies
- NSAIDs remain the initial medication of choice for chronic back pain when pharmacologic treatment is needed. 1, 5
- Duloxetine (an SNRI) may be beneficial for chronic low back pain. 5
- Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors should be used as part of a multimodal strategy for patients with chronic pain. 1
- Extended-release oral opioids should be used for back pain patients as part of a multimodal pain management strategy, with transdermal, sublingual, and immediate-release oral opioids also available. 1
- A strategy for monitoring and managing side effects, adverse effects, and compliance must be in place before prescribing any long-term pharmacologic therapy. 1
Treatments with Inconclusive Evidence
- Evidence is inconclusive to recommend benzodiazepines, muscle relaxants (for chronic use), antidepressants (except duloxetine), corticosteroids, insomnia agents, anticonvulsants, cannabis, acetaminophen, or long-term opioids. 5
Special Considerations for Radicular Pain and Spinal Stenosis
- Few trials have evaluated effectiveness of treatments specifically in patients with radicular pain or symptoms of spinal stenosis. 1
- Continuous or intermittent traction has not been shown effective in patients with sciatica. 1
- Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain. 5
Critical Pitfalls to Avoid
- Never prescribe bed rest or activity restriction—this provides no benefit and delays recovery. 1, 2
- Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events. 1, 2
- Monitor for hepatotoxicity when using acetaminophen at maximum doses (4g/day), especially in elderly patients or those with hepatic impairment. 2
- Do not obtain routine imaging unless red flags are present, there is a neuromuscular deficit, or pain does not resolve after 4-6 weeks of conservative therapy. 5, 6
- Passive methods (rest, medications alone) are associated with worsening disability and are not recommended as sole treatment. 7