What is the best course of action for a patient with chronic back pain for 3 months?

Management of Chronic Back Pain (3 Months Duration)

For a patient with 3-month chronic back pain, initiate nonpharmacologic treatment with exercise therapy as the cornerstone, combined with multidisciplinary rehabilitation, acupuncture, yoga, or cognitive behavioral therapy—reserving medications only for inadequate responders. 1

Initial Nonpharmacologic Treatment (First-Line)

Your patient has crossed into chronic low back pain territory (>12 weeks), which fundamentally changes the treatment approach from acute pain management. 1

Start with these evidence-based nonpharmacologic interventions: 1

• Exercise therapy (strongest recommendation): Individualized, supervised programs incorporating stretching and strengthening provide the best outcomes for 2-18 months 1, 2
• Multidisciplinary rehabilitation: Strong evidence for improving both pain and function for 4 months to 1 year 1, 2
• Acupuncture: Moderate-quality evidence for pain relief in chronic cases 1, 2
• Yoga or tai chi: Moderate effectiveness demonstrated 1
• Cognitive behavioral therapy: Provides relief lasting 4 weeks to 2 years 1, 2
• Spinal manipulation: Low-quality but supportive evidence for small to moderate benefits 1, 2
• Massage therapy: Moderate effectiveness for chronic pain 2
• Mindfulness-based stress reduction: Moderate-quality evidence 1

The American College of Physicians explicitly prioritizes these nonpharmacologic approaches over medications for chronic back pain, based on their 2017 guideline—the most recent high-quality guidance available. 1

When to Add Pharmacologic Treatment (Second-Line)

Only consider medications after inadequate response to nonpharmacologic therapy. 1

Medication Hierarchy:

1. NSAIDs (first-line pharmacologic): Use as initial medication if nonpharmacologic treatments fail 1, 3, 4
2. Tramadol or duloxetine (second-line): Consider if NSAIDs are inadequate or contraindicated 1, 4
3. Opioids (last resort only): Only after failure of all above treatments, and only if potential benefits outweigh risks after thorough discussion with patient 1

Avoid these medications as they lack evidence or carry excessive risk: 2, 4

• Systemic corticosteroids (no benefit over placebo) 2
• Benzodiazepines (abuse/addiction risk, use only time-limited if necessary) 2
• Long-term muscle relaxants (moderate evidence for acute use only, not chronic) 2
• Acetaminophen (insufficient evidence for chronic back pain) 4

Assessment Requirements Before Treatment

Before initiating any treatment, conduct a focused evaluation: 2

Pain characteristics to document: 2

• Location, quality, intensity, temporal patterns
• Aggravating/relieving factors
• Associated motor/sensory/autonomic changes (screen for radiculopathy)

Screen for red flags requiring immediate imaging/referral: 5

• Cauda equina symptoms (urinary retention, saddle anesthesia, bilateral leg weakness)
• Progressive neurological deficits
• History of cancer (especially bone metastases)
• Suspected infection (fever, recent infection, immunocompromised)
• Severe unrelenting pain worse at night

Screen for yellow flags predicting chronicity: 5

• Depression, anxiety, passive coping strategies
• Job dissatisfaction, disputed compensation claims
• Significant functional limitations

Evaluate for radiculopathy: 1

• If radicular symptoms present (leg pain, paresthesia, weakness), this requires a different treatment pathway with earlier specialist referral (within 3 months) 1

Imaging Decisions

Do NOT obtain routine imaging for nonspecific chronic back pain without red flags. 1, 5

Consider MRI only if: 5

• Red flags are present
• Pain persists beyond 1-2 months despite standard therapies
• Radiculopathy or spinal stenosis symptoms persist and patient is a candidate for epidural injections or surgery

Routine imaging in chronic nonspecific back pain leads to increased healthcare utilization, more surgeries, and higher disability without improving outcomes. 5

Specialist Referral Timing

Refer to a spine specialist if: 5, 2

• Pain does not respond to standard noninvasive therapies after 3 months
• Severe radiculopathy develops 1
• Functional disabilities persist despite comprehensive nonsurgical treatment

The British Pain Society recommends referral at 3 months (14 weeks from presentation) for patients with inadequate response to conservative management. 1

Long-Term Management Strategy

Develop a longitudinal approach with periodic follow-up evaluations focusing on pain reduction AND functional improvement. 2

• Use multidisciplinary programs whenever available rather than single-modality treatments 2
• Set realistic goals emphasizing function and rehabilitation, not just pain elimination 2
• Avoid bed rest—patients should remain active 1

Common Pitfalls to Avoid

• Don't rush to imaging: At 3 months without red flags, imaging is premature and counterproductive 1, 5
• Don't start with medications: The evidence strongly favors nonpharmacologic approaches first 1
• Don't use epidural injections for nonspecific back pain: These are only for radicular pain with specific indications 6, 4
• Don't promise complete pain elimination: Most chronic back pain improves but may not fully resolve; focus on functional restoration 2