What are the recommended treatment options for low back pain?

Treatment of Low Back Pain

Initial Management Strategy

Begin with nonpharmacologic therapies as first-line treatment for chronic low back pain, specifically exercise therapy combined with psychological interventions, and use NSAIDs as the preferred first-line medication for acute low back pain. 1, 2

The treatment approach differs fundamentally based on pain duration, requiring distinct strategies for acute versus chronic presentations.

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Acute Low Back Pain (< 4 weeks)

First-Line Pharmacologic Treatment

• NSAIDs are the preferred initial medication, providing small to moderate improvements in pain intensity compared to placebo 2
• Prescribe at the lowest effective doses for the shortest periods necessary, assessing cardiovascular and gastrointestinal risk factors before initiating therapy 2
• Acetaminophen can serve as an alternative first-line option due to favorable safety profile, though it shows no significant difference from placebo for pain intensity or function 2
• Most NSAIDs show no differences in head-to-head trials, so selection can be based on cost, availability, and individual patient factors 2

Essential Non-Pharmacologic Measures

• Advise patients to remain active and avoid bed rest, as activity restriction prolongs recovery and delays resumption of normal activities 2, 3
• Apply superficial heat via heating pads or heated blankets for short-term symptomatic relief 2, 3
• Provide reassurance about favorable prognosis, with 90% of acute episodes resolving within 6 weeks regardless of treatment 3

Second-Line Options When Initial Treatment Fails

• Skeletal muscle relaxants improve short-term pain relief compared to placebo after 2-7 days, though all are associated with central nervous system adverse effects, primarily sedation 2
• Spinal manipulation administered by appropriately trained providers provides small to moderate short-term benefits 2, 3
• Opioid analgesics or tramadol may be considered only when severe, disabling pain is not controlled with acetaminophen and NSAIDs, weighing substantial risks including aberrant drug-related behaviors, abuse potential, and addiction 2, 4

Treatments to Avoid in Acute Phase

• Do not prescribe bed rest or activity restriction, as this provides no benefit and delays recovery 2, 3
• Systemic corticosteroids are not recommended, as they have not been shown more effective than placebo 2, 3
• Benzodiazepines carry risks for abuse, addiction, and tolerance; if used, only prescribe time-limited courses 2
• Insufficient evidence exists to recommend antidepressants or antiseizure medications 2

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Chronic Low Back Pain (> 12 weeks)

First-Line Nonpharmacologic Therapies (Prioritize These)

Exercise therapy should be the cornerstone of treatment, with moderate evidence demonstrating effectiveness for both pain reduction and functional improvement 1, 3

Psychological Interventions

• Cognitive-behavioral therapy shows good evidence for moderate efficacy in reducing pain and improving function 1, 3
• Mindfulness-based stress reduction is as effective as cognitive behavioral therapy, with moderate strength of evidence 1

Manual Therapies

• Spinal manipulation demonstrates fair to moderate evidence for pain relief and functional improvement 1, 3
• Massage therapy shows moderate effectiveness, including deep tissue massage and myofascial release techniques 1

Mind-Body Interventions

• 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
• Tai chi produces moderate pain improvement compared to wait-list controls, though evidence strength is low 1
• Acupuncture is supported by low to moderate evidence for effectiveness 1, 3

Second-Line Pharmacologic Therapy (Only for Inadequate Response to Nonpharmacologic Treatment)

• Continue NSAIDs if effective from acute phase 3
• Duloxetine starting at 30 mg daily, titrating to 60 mg daily, is a second-line pharmacologic option for patients with inadequate response to NSAIDs 1, 3
• Tramadol is an alternative second-line agent 1
• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) can be used as part of a multimodal strategy 1, 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, 3

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Critical Pitfalls to Avoid

• Never prescribe bed rest, as it leads to deconditioning, muscle atrophy, and worse outcomes 1, 3
• Do not routinely order imaging for nonspecific chronic low back pain, as MRI or CT findings are often nonspecific and do not improve outcomes or guide treatment decisions 1, 3
• Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS 1
• Continuous or intermittent traction has not been proven effective 1, 3
• Lumbar supports lack clear evidence of benefit 1
• Systemic corticosteroids show no superiority over placebo 1
• Opioids should be avoided due to limited evidence of long-term effectiveness and significant risks 1
• Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events 2

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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 3

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When to Consider Specialist Referral

• Consider consultation with a back specialist after a minimum of 3 months of failed nonsurgical interventions 1
• Consider MRI and specialist referral if symptoms persist beyond 4 weeks despite conservative management, particularly with radicular symptoms 3
• Evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk 5

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Special Considerations

Screen and treat depression appropriately as it commonly coexists with chronic back pain 3

Consider gabapentin for radicular symptoms 3

Early return to work is associated with less long-term disability; modified work is preferable to complete work absence 3