What is the best approach to manage persistent lower back pain in a patient with no contraindications?

Management of Persistent Lower Back Pain

For persistent (chronic) lower back pain, begin with nonpharmacologic treatments—specifically exercise therapy, multidisciplinary rehabilitation, or acupuncture—and only add NSAIDs if these fail after 4-6 weeks, reserving tramadol or duloxetine as second-line options and opioids as a last resort. 1, 2

Initial Nonpharmacologic Approach (First-Line Treatment)

Chronic low back pain (lasting >12 weeks) should be managed initially without medications. The following therapies have the strongest evidence base:

Highest Priority Interventions:

• Exercise therapy is the cornerstone of treatment and demonstrates good evidence of moderate efficacy—the specific type matters less than patient adherence 2, 3
• Multidisciplinary rehabilitation combining physical, psychological, and educational interventions shows moderate-quality evidence of effectiveness, particularly when intensive 1, 2
• Acupuncture provides modest pain relief with moderate-quality evidence 1, 2
• Mindfulness-based stress reduction shows moderate-quality evidence for improvements in both pain and function 1, 2

Additional Effective Options:

• Cognitive behavioral therapy demonstrates good evidence of moderate efficacy and should address psychosocial factors that complicate chronic pain 1, 2
• Yoga (particularly Iyengar yoga) results in moderately lower pain scores and improved function at 24 weeks compared to usual care 1, 2
• Tai chi produces moderate pain improvement compared to wait-list controls 1, 2
• Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 1, 2
• Massage therapy shows moderate effectiveness for chronic low back pain 2, 4
• Motor control exercise specifically targets spinal-supporting muscles and moderately decreases pain scores 1, 2

Pharmacologic Treatment Algorithm (Second-Line)

Only proceed to medications if nonpharmacologic therapy provides inadequate response after 4-6 weeks. 1, 2

Step 1: NSAIDs (First-Line Pharmacologic)

• Use NSAIDs such as naproxen or ibuprofen as first-line pharmacologic therapy 1, 2
• NSAIDs show moderate-quality evidence for small to moderate pain improvement and small improvement in function 1
• Most head-to-head trials show no differences between different NSAIDs 1

Step 2: Tramadol or Duloxetine (Second-Line)

• If NSAIDs provide inadequate response, add tramadol (which achieves moderate short-term pain relief) or duloxetine (starting at 30 mg daily and titrating to 60 mg daily) 1, 2
• Moderate-quality evidence supports tramadol for moderate pain relief and small functional improvement 1

Step 3: Tricyclic Antidepressants (Alternative Second-Line)

• Consider tricyclic antidepressants such as amitriptyline 10-25 mg at bedtime as part of a multimodal strategy 2, 4

Step 4: Opioids (Last Resort Only)

• Only consider opioids after failure of all above treatments and only if potential benefits outweigh risks 1, 2
• Requires thorough discussion of known risks and realistic benefits with patients 1
• Strong opioids show only small short-term improvement (about 1 point on a 0-10 pain scale) with moderate-quality evidence 1

Critical Management Principles

What to Avoid:

• Never prescribe bed rest—it leads to deconditioning and worsens outcomes; patients must remain active 5, 2, 6
• Avoid routine imaging for nonspecific low back pain as it does not improve outcomes and may lead to unnecessary interventions 1, 2, 6
• Do not use TENS—it shows no difference compared to sham TENS for pain intensity or function 2, 4
• Avoid lumbar supports—they have not shown clear benefits for chronic back pain 2, 4
• Do not use systemic corticosteroids—they show no greater efficacy than placebo 1, 2
• Avoid interventional procedures such as epidural injections, radiofrequency ablation, and joint injections as they lack evidence of benefit 4

Realistic Expectations:

• The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate (5-20 points on a 100-point scale) and generally short-term 2, 4
• Effects on function are generally smaller than effects on pain 2, 4
• Up to one-third of patients report persistent moderate pain at 1 year despite treatment 1, 5

When to Reassess and Escalate

Timing of Reevaluation:

• Reevaluate at 1 month if symptoms persist without improvement 5
• Consider earlier reassessment in patients over 65 years, with signs of radiculopathy/stenosis, or worsening symptoms 5

Escalation Criteria:

• If inadequate response after 4-6 weeks of nonpharmacologic therapy, add NSAIDs 1, 2
• If still inadequate response, consider referral for multidisciplinary rehabilitation 2
• Consider imaging only if symptoms persist beyond 4-6 weeks without improvement and patient has not responded to conservative therapy 1, 5

Referral Indications:

• No response to standard noninvasive therapies after 3 months minimum 5
• Progressive neurologic deficits 5
• Persistent functional disabilities and pain despite comprehensive conservative therapy 5

Special Considerations for Combination Therapy

Effective Combinations:

• Heat therapy combined with exercise provides greater pain relief than exercise alone 4
• Combining multiple nonpharmacologic approaches (e.g., exercise + cognitive behavioral therapy + acupuncture) based on patient preference is reasonable 2

Combination with NSAIDs:

• Cyclobenzaprine (skeletal muscle relaxant) combined with naproxen was associated with more side effects than naproxen alone, primarily drowsiness, without clear additional benefit 7
• No well-controlled studies demonstrate that cyclobenzaprine enhances the clinical effect of analgesics 7