What is the best management approach for a patient with chronic back pain, considering non-pharmacological and pharmacological interventions?

Management of Chronic Back Pain

Start with Nonpharmacologic Therapy—This is First-Line Treatment

For chronic low back pain, begin with nonpharmacologic interventions as your primary treatment strategy, specifically exercise therapy combined with psychological approaches, before considering any medications. 1, 2, 3

Core Nonpharmacologic Interventions (Choose Based on Patient Preference and Access)

Exercise therapy is the cornerstone and should be prescribed to virtually all patients:

• Structured, supervised exercise programs incorporating stretching and strengthening demonstrate good evidence for moderate efficacy in reducing pain and improving function 1, 2, 4
• Benefits include 10-20 points improvement on a 100-point pain scale and 2-4 points on the Roland-Morris Disability Questionnaire 1
• Tailor the program to patient capabilities and gradually increase intensity as tolerated 2

Add psychological interventions early:

• Cognitive-behavioral therapy shows good evidence for moderate efficacy and should be implemented to address psychosocial factors contributing to pain 1, 2, 4
• Mindfulness-based stress reduction is equally effective as cognitive-behavioral therapy with moderate-quality evidence 1, 2, 3
• These approaches improve both pain scores and functional outcomes 1, 5

Consider complementary therapies based on patient preference:

• Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 1, 2, 4
• Massage therapy (including deep tissue and myofascial release) shows moderate effectiveness 1, 2, 4
• Acupuncture has low to moderate evidence for modest pain relief 1, 2, 4
• Yoga (particularly Iyengar or Viniyoga styles) results in moderately lower pain scores at 24 weeks compared to usual care 1, 2, 3
• Tai chi produces moderate pain improvement compared to wait-list controls 1, 2, 3

Set Realistic Expectations

• Pain benefits are typically small to moderate (5-20 points on a 100-point scale) and generally short-term, with effects most pronounced immediately after intervention 2, 3
• Functional improvements are generally smaller than pain improvements 1, 2
• Most patients require ongoing engagement with these therapies rather than a "cure" 4

Pharmacologic Therapy—Only After Inadequate Response to Nonpharmacologic Treatment

If patients have inadequate response after 4-6 weeks of nonpharmacologic therapy, add medications in this specific sequence: 1, 2, 3

First-Line Pharmacologic: NSAIDs

• Prescribe NSAIDs (such as naproxen or ibuprofen) as first-line pharmacologic therapy 1, 2, 3
• Continue effective nonpharmacologic treatments while adding NSAIDs 2, 3

Second-Line Pharmacologic: Tramadol or Duloxetine

• Duloxetine 30 mg daily, titrating to 60 mg daily is a second-line option with moderate-quality evidence 1, 2, 3, 6
• Duloxetine demonstrated statistically significant pain reduction in chronic low back pain trials, with patients achieving at least 50% pain reduction 6
• Tramadol is an alternative second-line agent 1, 2, 3
• The 120 mg duloxetine dose showed no additional benefit over 60 mg and was associated with more adverse reactions 6

Third-Line Pharmacologic: Tricyclic Antidepressants

• Consider amitriptyline 10-25 mg at bedtime as part of a multimodal strategy if inadequate response to above measures 2, 3, 7

Last Resort: Opioids (Rarely Appropriate)

• Consider opioids only after failure of all above treatments and only if potential benefits outweigh risks 1, 2, 3
• Requires thorough discussion of known risks and realistic benefits with patients 1
• Limited evidence of long-term effectiveness with significant risks 3

Intensive Intervention for Refractory Cases

For patients not responding after 4-6 weeks of the above approach, refer for multidisciplinary rehabilitation: 2, 3

• Intensive programs combining physical therapy, psychological interventions, and educational components show good evidence of moderate effectiveness 1, 2, 4
• This is particularly effective for reducing work absenteeism 7

Consider specialist consultation after minimum of 3 months of failed nonsurgical interventions 3

Critical Pitfalls to Avoid

Do not order routine imaging:

• MRI or CT findings are often nonspecific and do not improve outcomes or guide treatment decisions for nonspecific chronic low back pain 2, 3, 7
• Only obtain imaging when severe/progressive neurologic deficits are present, serious underlying conditions are suspected, or for persistent symptoms in surgical candidates 7

Do not prescribe bed rest:

• Bed rest leads to deconditioning, muscle atrophy, and worse outcomes 2, 3, 7
• Patients should remain as active as tolerated 7

Avoid ineffective therapies:

• Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS 2, 3
• Continuous or intermittent traction has not been proven effective 2, 3, 7
• Lumbar supports lack clear evidence of benefit 2, 3
• Systemic corticosteroids show no superiority over placebo 2, 7

Treatment Algorithm Summary

1. Weeks 0-6: Prescribe structured exercise program + cognitive-behavioral therapy or mindfulness-based stress reduction + complementary therapy based on patient preference (yoga, tai chi, massage, spinal manipulation, or acupuncture) 1, 2, 3

2. Weeks 4-6 (if inadequate response): Add NSAIDs as first-line pharmacologic therapy while continuing effective nonpharmacologic treatments 1, 2, 3

3. Weeks 4-6 (if still inadequate response): Consider referral for intensive multidisciplinary rehabilitation 2, 3

4. Weeks 8-12 (if still inadequate response): Add duloxetine 30-60 mg daily or tramadol as second-line pharmacologic therapy 1, 2, 3

5. Weeks 12+ (if still inadequate response): Consider tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) 2, 3

6. After 3+ months of failed interventions: Consider specialist referral and, only as last resort after thorough risk-benefit discussion, opioids 1, 2, 3