Treatment of Back Pain
First-Line Treatment Approach
For acute low back pain, start with NSAIDs (such as ibuprofen 400 mg every 4-6 hours, maximum 3200 mg daily) combined with advice to remain active and avoid bed rest. 1, 2
Pharmacologic Management
NSAIDs are the preferred first-line medication, providing small to moderate improvements in pain intensity compared to placebo, with moderate-quality evidence supporting their use. 1, 2 Most head-to-head trials show no meaningful differences between individual NSAIDs, so selection can be based on cost and patient-specific factors. 1, 2
Acetaminophen (up to 3000 mg daily) is an alternative first-line option due to its favorable safety profile, though evidence shows no significant difference from placebo for pain or function. 1, 2 Lower doses should be used in patients with hepatic impairment, malnutrition, or severe alcohol use. 3
Prescribe NSAIDs at the lowest effective dose for the shortest duration, assessing cardiovascular and gastrointestinal risk factors before initiating therapy. 2 Use caution in patients with history of GI bleeding, cardiovascular disease, or chronic kidney disease. 3
Essential Non-Pharmacologic Measures
Advise patients to remain active and avoid bed rest, as activity restriction prolongs recovery and delays return to normal function. 2, 4, 5 This recommendation carries strong evidence and should be emphasized at every visit. 5
Apply superficial heat via heating pads for short-term symptomatic relief in acute low back pain. 2, 4
Second-Line Options When Initial Treatment Fails
Adding Skeletal Muscle Relaxants
If severe pain persists after 2-4 days of NSAIDs, add a skeletal muscle relaxant for short-term use (≤1-2 weeks). 1, 2, 6 Moderate-quality evidence shows skeletal muscle relaxants improve pain relief at 2-4 and 5-7 days compared to placebo. 1, 2
Cyclobenzaprine has the strongest evidence among muscle relaxants, with demonstrated superiority over placebo for acute low back pain. 6, 7 Start with 5 mg three times daily, particularly in elderly patients or those with hepatic impairment, and titrate slowly upward if needed. 7
All skeletal muscle relaxants cause sedation as their primary adverse effect. 2 No compelling evidence exists that different agents differ in efficacy, though individual medications carry unique risks. 2
Do not prescribe muscle relaxants beyond 1-2 weeks, as there is no evidence supporting longer duration and risks increase with prolonged use. 6
Non-Pharmacologic Interventions
For patients not improving with self-care after 4 weeks, add spinal manipulation administered by appropriately trained providers (chiropractors, osteopaths, physical therapists), which provides small to moderate short-term benefits. 2, 4
Consider acupuncture, massage therapy, or yoga as additional options with moderate evidence for chronic low back pain. 4
Management of Chronic Low Back Pain (>12 weeks)
Pharmacologic Options
NSAIDs remain effective for chronic low back pain, providing small to moderate pain improvement with moderate-quality evidence. 1 Continue if beneficial, using the lowest effective dose. 4
Add tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors (SNRIs) as part of multimodal therapy. 1, 4 Tricyclic antidepressants show good evidence with small to moderate benefit for chronic low back pain. 1 Duloxetine is the only antidepressant with demonstrated efficacy. 8
For radicular symptoms, consider gabapentin starting at low doses and titrating based on response. 1, 6, 4
Non-Pharmacologic Therapies (Cornerstone of Chronic Management)
Exercise therapy should be a cornerstone of chronic low back pain treatment, with good evidence of moderate efficacy. 4, 9 No single type of exercise is superior to another; participation can be individual or group-based. 9
Cognitive-behavioral therapy demonstrates good evidence of moderate efficacy and should be incorporated for chronic low back pain. 1, 4
Intensive interdisciplinary rehabilitation combining physical, psychological, and educational interventions shows good evidence of effectiveness for reducing work absenteeism and improving function. 4
Opioid Considerations
Reserve opioids only for severe, disabling pain not controlled with acetaminophen and NSAIDs. 2 For chronic low back pain, moderate-quality evidence shows strong opioids (morphine, hydromorphone, oxymorphone) provide small short-term improvement (approximately 1 point on 0-10 scale) in pain and function. 1
Tramadol achieves moderate short-term pain relief with a small improvement in function compared to placebo. 1
Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction, requiring careful weighing of benefits and harms before initiating therapy. 2 If prescribed, use time-limited courses with clear monitoring plans. 1
Treatments NOT Recommended
Do not prescribe systemic corticosteroids for acute or chronic low back pain with or without sciatica, as they show no greater efficacy than placebo. 1, 2, 4
Avoid benzodiazepines except in rare circumstances, as they carry risks for abuse, addiction, and tolerance similar to muscle relaxants but without superior efficacy. 2, 4
Do not routinely order imaging for nonspecific low back pain without red flags, as it does not improve outcomes and may lead to unnecessary interventions. 6, 4, 10
Insufficient evidence exists to recommend antidepressants (except tricyclics and SNRIs) or antiseizure medications for acute low back pain. 2
Critical Red Flags Requiring Urgent Evaluation
Obtain immediate imaging (MRI preferred) if any of the following are present:
- Progressive motor or sensory loss 8
- New urinary retention or overflow incontinence (cauda equina syndrome) 8, 5
- History of cancer 8
- Recent invasive spinal procedure 8
- Significant trauma relative to age 8
- Fever with suspicion of infection 5
Common Pitfalls to Avoid
Never prescribe bed rest or activity restriction, as this provides no benefit and delays recovery. 2, 4, 5
Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events. 2
Avoid overreliance on imaging, as findings on MRI or CT are often nonspecific and do not correlate with clinical outcomes. 4, 10
Do not overlook psychosocial factors and comorbid depression, which commonly coexist with chronic back pain and require appropriate screening and treatment. 4, 10