What are the treatment options for back pain?

Treatment for Back Pain

Start with NSAIDs and advise the patient to remain active—this combination provides the most effective initial management for back pain. 1, 2

Initial Assessment Priorities

Before initiating treatment, rapidly screen for red flags requiring urgent intervention: 1, 3

• Cauda equina syndrome (new urinary retention, overflow incontinence, saddle anesthesia) 1, 4
• Progressive neurological deficits (motor weakness, sensory loss) 1, 4
• Infection or malignancy (fever, unexplained weight loss, history of cancer, immunosuppression) 1, 4
• Fracture risk (significant trauma relative to age, osteoporosis, prolonged corticosteroid use) 1, 4

Do not routinely obtain imaging for nonspecific low back pain—reserve MRI only for patients who are surgical candidates or need epidural steroid injection with symptoms persisting beyond 4-6 weeks. 1, 5

First-Line Treatment (All Patients)

Pharmacologic Management

NSAIDs are the preferred first-line medication, providing small to moderate pain relief superior to acetaminophen: 1, 2, 5

• Ibuprofen 400mg every 4-6 hours (maximum 3200mg daily, though doses above 400mg show no additional benefit for acute pain) 2, 6
• Prescribe at the lowest effective dose for the shortest duration 2, 6
• Assess cardiovascular and gastrointestinal risk factors before prescribing 2
• Take with meals or milk if gastrointestinal complaints occur 6

Acetaminophen is an acceptable alternative for patients with NSAID contraindications, though it shows no significant difference from placebo in acute low back pain: 2, 5

• Maximum 3000-4000mg daily 2, 5
• Monitor for hepatotoxicity in elderly patients or those with liver disease 2

Non-Pharmacologic Management

Advise patients to remain active and avoid bed rest—activity restriction prolongs recovery and delays return to normal function. 1, 2, 5, 7

Apply superficial heat via heating pads or heated blankets for short-term symptomatic relief. 2, 5

Provide evidence-based self-care education materials and reassurance about favorable prognosis (most patients improve within 4-6 weeks). 1, 5

Second-Line Treatment (If No Improvement After 1-2 Weeks)

For Acute Pain (<4 weeks)

Skeletal muscle relaxants improve short-term pain relief after 2-7 days: 2

• All agents cause central nervous system adverse effects, primarily sedation 2
• Prescribe time-limited courses only 2
• No evidence that different muscle relaxants differ in efficacy 2

Spinal manipulation by appropriately trained providers (chiropractor or other trained clinician) shows small to moderate short-term benefits: 8, 1, 2, 5

• Benefits do not vary by profession of manipulator 8
• Can be considered as part of comprehensive treatment plan 1

For Subacute/Chronic Pain (>4 weeks)

Expand treatment options to include multiple moderately effective therapies: 8, 5

• Exercise therapy (individually tailored, supervised, incorporating stretching and strengthening) 8, 5, 9
• Cognitive-behavioral therapy or progressive relaxation 8, 5
• Acupuncture 8, 5
• Massage therapy 8, 5
• Yoga (Viniyoga-style) 8, 5
• Intensive interdisciplinary rehabilitation (physician consultation coordinated with psychological, physical therapy, social, or vocational intervention) 8, 5

For chronic pain, add antidepressants as part of multimodal strategy: 8, 5

• Tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) 8, 5
• Selective serotonin reuptake inhibitors may be considered for diabetic neuropathy specifically 8

Physical or restorative therapy (physiotherapy, fitness classes, exercise therapy) provides effective relief for 2-18 months. 8

Third-Line Treatment (Severe, Disabling Pain)

Reserve opioids only for severe, disabling pain uncontrolled by NSAIDs: 1, 2

• Extended-release oral opioids should be used for back pain patients as part of multimodal strategy 8
• Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction 2
• Extended medication courses should only continue if patient shows clear ongoing benefits without major adverse events 8, 1
• Establish monitoring strategy for side effects, adverse effects, and compliance before prescribing long-term therapy 8

Treatments NOT Recommended

Avoid these interventions that lack evidence or cause harm: 2, 5

• Bed rest or activity restriction—provides no benefit and delays recovery 2, 5
• Systemic corticosteroids—not more effective than placebo for acute low back pain with or without sciatica 2, 5
• Benzodiazepines—similar effectiveness to muscle relaxants but carry risks for abuse, addiction, and tolerance 2, 5
• Continuous or intermittent traction—not effective for chronic low back pain or sciatica 8, 5
• Transcutaneous electrical nerve stimulation (TENS)—not proven effective 8
• Antidepressants or antiseizure medications for acute low back pain—insufficient evidence 2

Special Considerations

For radicular symptoms (sciatica): 5

• Consider gabapentin for radicular symptoms 5
• Most other medications lack evidence specifically for sciatica 8
• Obtain MRI and specialist referral if symptoms persist beyond 4 weeks despite conservative management 5

Screen and treat depression appropriately—it commonly coexists with chronic back pain and affects outcomes. 5

Critical Pitfalls to Avoid

• Do not overuse imaging—findings on MRI or CT are often nonspecific and do not improve outcomes 5
• Do not prescribe extended medication courses without documented ongoing benefits and absence of major adverse events 8, 1
• Do not rely on passive treatments—active strategies like exercise decrease disability, while passive methods (rest, medications alone) worsen disability 7, 9
• Patient expectations influence outcomes—consider them when choosing interventions 8