What are the best management options for a relatively healthy adult with chronic lower back pain?

Management of Chronic Lower Back Pain in Relatively Healthy Adults

Begin with exercise therapy combined with acetaminophen or NSAIDs, avoiding interventional procedures and imaging unless red flags are present. 1, 2

First-Line Treatment Approach

Start with nonpharmacologic therapy as the foundation:

• Exercise therapy is the cornerstone of treatment and demonstrates moderate efficacy for pain relief (10-20 points on a 100-point scale) and functional improvement. 1, 3 No single exercise type is superior to another—walking, stretching, strengthening, or group programs all provide benefit. 4

• Provide reassurance and education that chronic low back pain typically improves with continued activity rather than rest, and that remaining active prevents deconditioning and worsening disability. 2, 3 Bed rest should be completely avoided as it leads to muscle atrophy and slower recovery. 3

• Add cognitive-behavioral therapy if pain persists, as it provides moderate benefits (10-20 points on a 100-point pain scale) and helps prevent chronic disability. 1, 3

For pharmacologic therapy:

• Acetaminophen (up to 3000 mg/day) is the safest first-line option, particularly in older adults, despite being slightly less effective than NSAIDs. 2

• NSAIDs provide superior pain relief but require careful consideration of cardiovascular, renal, and gastrointestinal risks. 1, 2 Use ibuprofen 400 mg every 4-6 hours (maximum 3200 mg/day) or naproxen at the lowest effective dose for the shortest duration. 5

Second-Line Nonpharmacologic Options

If exercise and first-line medications provide insufficient relief, add:

• Spinal manipulation provides moderate benefits (10-19 points on a 100-point pain scale) and is remarkably safe with serious adverse events occurring in less than 1 per 1 million visits. 1, 6 Effects are comparable to physical therapy and exercise. 1

• Massage therapy shows similar efficacy to other noninvasive interventions for chronic low back pain. 1

• Acupuncture demonstrates fair evidence of effectiveness, superior to sham acupuncture for chronic pain. 1

• Mind-body interventions including yoga, tai chi, and mindfulness-based stress reduction show moderate evidence of benefit. 1

Second-Line Pharmacologic Options

When first-line medications are inadequate:

• Duloxetine (30 mg daily, titrating to 60 mg daily) is the preferred second-line agent for chronic low back pain. 1, 2

• Tricyclic antidepressants may provide pain relief but require caution in older adults due to anticholinergic effects (confusion, falls). 1, 2

Intensive Interventions for Refractory Cases

• Multidisciplinary rehabilitation combining physical therapy, psychological interventions, and education shows moderate to large benefits and is particularly effective for reducing work absenteeism. 1, 3

• Refer to multidisciplinary pain management when pain persists despite optimized first-line and second-line therapies. 2

Critical Interventions to AVOID

The 2025 BMJ guideline issues strong recommendations AGAINST these procedures for chronic axial spine pain: 2

• Radiofrequency ablation of joints
• Epidural injections (local anesthetic, steroids, or combination)
• Joint-targeted injections (local anesthetic, steroids, or combination)
• Intramuscular injections of local anesthetic

These interventions lack evidence of benefit and should not be offered. 2

Imaging and Red Flag Assessment

• Do NOT routinely obtain imaging for nonspecific chronic low back pain, as findings are often nonspecific and do not improve outcomes. 2, 3

• Obtain MRI or CT only when: 3

  • Progressive neurological deficits are present
  • Cauda equina syndrome is suspected
  • Infection or malignancy is suspected
  • Symptoms persist in surgical candidates

Opioid Considerations

• Opioids should NOT be first-line or routine therapy for chronic low back pain. 1

• Consider opioids only after documented failure of all other therapies and when potential benefits clearly outweigh risks. 2

• Before initiating opioids, conduct thorough risk assessment including screening for substance use disorder, mental health conditions, and concurrent sedative use. 2

Common Pitfalls to Avoid

• Avoid passive physical therapies (interferential therapy, traction, ultrasound, lumbar supports, TENS) as they lack evidence of effectiveness. 1, 2

• Avoid systemic corticosteroids as they show no greater efficacy than placebo. 3

• Do not prescribe prolonged bed rest as it worsens outcomes through deconditioning. 3

• Avoid overreliance on imaging findings to guide treatment, as degenerative changes are common in asymptomatic individuals and do not correlate with pain severity. 3