What are the treatment options for chronic low back pain?

Treatment of Chronic Low Back Pain

Begin with nonpharmacologic therapies as first-line treatment for chronic low back pain, specifically exercise therapy combined with psychological interventions, reserving medications for patients who do not respond adequately to these initial approaches. 1, 2

First-Line Nonpharmacologic Therapies

Exercise therapy should be the cornerstone of treatment for chronic low back pain, with moderate evidence demonstrating effectiveness for both pain reduction and functional improvement. 1, 2 Programs that incorporate individual tailoring, supervision, stretching, and strengthening produce the best outcomes, though the specific type of exercise matters less than patient adherence. 1, 3 The magnitude of benefit is typically moderate (10-20 points on a 100-point pain scale), with effects primarily seen in the short term (usually less than 3 months). 1

Psychological interventions demonstrate moderate effectiveness and should be implemented early:

• Cognitive-behavioral therapy shows good evidence for moderate efficacy in reducing pain and improving function 1, 2
• Mindfulness-based stress reduction is as effective as cognitive behavioral therapy, with moderate strength of evidence 1
• These interventions address psychosocial factors that predict chronic disability and should not be delayed until other treatments fail 2

Manual therapies provide small to moderate short-term benefits:

• Spinal manipulation demonstrates fair to moderate evidence for pain relief and functional improvement 1, 2
• Massage therapy shows moderate effectiveness, including deep tissue massage and myofascial release techniques 1, 3
• Benefits do not vary significantly based on the profession of the manipulator (chiropractor vs. other trained clinician) 1

Mind-body interventions offer additional options:

• Yoga (particularly Viniyoga or Iyengar styles) results in moderately lower pain scores and improved function at 24 weeks compared to usual care, with moderate strength of evidence 1, 3
• Tai chi produces moderate pain improvement compared to wait-list controls, though evidence strength is low 1, 3
• Acupuncture is supported by low to moderate evidence for effectiveness in chronic low back pain 1

Superficial heat application provides moderate pain relief and disability reduction when combined with exercise, offering greater benefits than exercise alone. 2, 3

Pharmacologic Therapy for Inadequate Response

Add NSAIDs as first-line pharmacologic therapy when nonpharmacologic approaches provide insufficient relief:

• Ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily, though doses above 400 mg show no additional benefit in controlled trials) 4
• Naproxen is an alternative NSAID option 2, 3
• Use the lowest effective dose for the shortest duration, and administer with meals or milk if gastrointestinal complaints occur 4

Second-line pharmacologic options for patients with inadequate response to NSAIDs:

• Duloxetine starting at 30 mg daily, titrating to 60 mg daily 3
• Tramadol as an alternative second-line agent 3
• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) as part of a multimodal strategy 2, 3

Intensive Interventions for Refractory Cases

Intensive multidisciplinary rehabilitation combining physical therapy, psychological interventions, and educational components shows good evidence of moderate effectiveness for chronic low back pain that has not responded to simpler interventions. 1 This approach is particularly effective for reducing work absenteeism in occupational settings when it includes a cognitive-behavioral component. 1, 2

Critical Pitfalls to Avoid

Do not prescribe bed rest as it leads to deconditioning, muscle atrophy, and worse outcomes; patients must remain active within pain limits. 2, 3

Avoid routine imaging for nonspecific chronic low back pain, as MRI or CT findings are often nonspecific and do not improve outcomes or guide treatment decisions. 2, 3

Do not use these ineffective interventions:

• Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS 1, 3
• Continuous or intermittent traction has not been proven effective 1, 5
• Lumbar supports lack clear evidence of benefit 3, 5
• Systemic corticosteroids show no superiority over placebo 2, 5

Avoid overreliance on opioids due to limited evidence of long-term effectiveness and significant risks. 5

Realistic Outcome Expectations

Pain benefits are typically small to moderate in magnitude (5-20 points on a 100-point scale), with effects generally short-term and most pronounced immediately after intervention. 1, 3 Effects on function are generally smaller than effects on pain, though exercise therapy and multidisciplinary rehabilitation show more consistent functional improvements. 1 Most interventions demonstrate benefits primarily in the short term (less than 3 months), emphasizing the importance of ongoing adherence to active therapies like exercise. 1

Specialist Referral Considerations

Consider consultation with a back specialist after a minimum of 3 months of failed nonsurgical interventions, though this timing is somewhat arbitrary. 1 Referral decisions should account for patient symptoms, response to interventions, and availability of specialists with relevant expertise, recognizing that trials of surgery for nonspecific low back pain included only patients with at least 1 year of symptoms. 1