What is the best treatment for a patient with chronic back pain and no significant medical comorbidities?

Treatment of Chronic Back Pain

Initial Treatment: Start with Nonpharmacologic Therapy

For patients with chronic low back pain, begin with nonpharmacologic treatments—specifically exercise therapy, multidisciplinary rehabilitation, or cognitive behavioral therapy—as these demonstrate the strongest evidence for improving both pain and function while avoiding medication-related harms. 1, 2

First-Line Nonpharmacologic Options (Choose Based on Availability and Patient Preference)

Therapies with good evidence of moderate efficacy:

• Exercise therapy (structured programs tailored to patient capabilities, focusing on core strengthening and flexibility) 1, 2
• Cognitive behavioral therapy (addresses pain catastrophizing, fear-avoidance behaviors, and psychological factors) 1, 2
• Multidisciplinary rehabilitation (combining physical therapy, psychological intervention, and patient education delivered intensively) 1, 2
• Spinal manipulation (provides moderate pain relief and functional improvement) 1, 2

Therapies with fair to moderate evidence:

• Acupuncture (modest pain relief, particularly when combined with other modalities) 1, 2
• Mindfulness-based stress reduction (moderate-quality evidence for pain and function improvement) 1, 2
• Yoga (particularly Iyengar style, showing moderate pain reduction compared to usual care) 1, 2
• Tai chi (moderate pain improvement versus wait-list controls) 1, 2
• Massage therapy (moderate effectiveness for chronic low back pain) 1, 2

Set Realistic Expectations

The magnitude of benefit from nonpharmacologic therapies is typically small to moderate—expect 10 to 20 points improvement on a 100-point pain scale, or 2 to 4 points on the Roland-Morris Disability Questionnaire. 1, 2 Effects on function are generally smaller than effects on pain. 2

Critical Pitfalls to Avoid

• Do not recommend bed rest—it worsens outcomes and delays recovery 2
• Avoid routine imaging for nonspecific low back pain, as it does not improve outcomes and may lead to unnecessary interventions 2
• Do not use TENS units—transcutaneous electrical nerve stimulation shows no difference compared to sham treatment 2
• Lumbar supports lack clear benefit for chronic back pain 2

Pharmacologic Treatment: Only After Inadequate Response to Nonpharmacologic Therapy

First-Line Pharmacologic: NSAIDs

If nonpharmacologic therapy provides inadequate relief after 4-6 weeks, add NSAIDs as first-line pharmacologic therapy. 1, 2 NSAIDs provide approximately 10 points of pain relief on a 100-point scale. 2 Use the lowest effective dose for the shortest duration, assessing cardiovascular and gastrointestinal risk factors before prescribing. 2

Second-Line Pharmacologic Options

If NSAIDs are ineffective or contraindicated, use tramadol or duloxetine as second-line therapy. 1, 2

• Duloxetine is particularly beneficial when neuropathic pain components exist or when comorbid depression is present 3
• Duloxetine 60 mg once daily demonstrated statistically significant pain reduction in chronic low back pain trials, with some patients experiencing benefit as early as week 1 3
• The 120 mg dose showed no additional benefit over 60 mg and was associated with more adverse reactions 3

Third-Line: Tricyclic Antidepressants

Consider tricyclic antidepressants (such as amitriptyline 10-25 mg at bedtime) as part of a multimodal strategy if second-line agents fail. 2

Last Resort: Opioids (With Extreme Caution)

Only consider opioids after failure of all above treatments, and only if potential benefits outweigh risks after thorough discussion with the patient about known harms and realistic benefits. 1, 2 The evidence for long-term opioid use in chronic low back pain is poor, and risks of dependence, abuse, and adverse effects are substantial. 1

Medications to Avoid

• Systemic corticosteroids have not shown efficacy greater than placebo 2
• Benzodiazepines carry high risks of abuse, addiction, and tolerance with equivocal evidence for chronic pain 2
• Acetaminophen lacks strong evidence for chronic low back pain 1

Treatment Algorithm Summary

1. Weeks 0-6: Prescribe structured exercise program + cognitive behavioral therapy or mindfulness-based stress reduction 1, 2

2. Weeks 0-6 (concurrent): Add complementary approaches based on patient preference: yoga, tai chi, acupuncture, massage, or spinal manipulation 1, 2

3. Week 6 assessment: If inadequate response, continue effective nonpharmacologic treatments and add NSAIDs 1, 2

4. Week 6 (if needed): Consider referral for multidisciplinary rehabilitation if not already implemented 1, 2

5. Week 12 assessment: If still inadequate response, add tramadol or duloxetine 60 mg daily 1, 2, 3

6. Week 16-20 assessment: If persistent inadequate response, consider tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) 2

7. Last resort only: Consider opioids only after thorough risk-benefit discussion if severe pain persists despite all above measures 1, 2