What is the recommended management plan and treatment for an adult with chronic mechanical low back pain lasting more than one year, aggravated by forward bending and prolonged sitting, and without red‑flag symptoms?

Management Plan for Chronic Mechanical Low Back Pain

Begin with nonpharmacologic therapy as first-line treatment, specifically individualized supervised exercise combined with heat application, while avoiding bed rest and maintaining normal activities. 1, 2

Initial Assessment and Red Flag Screening

• Screen immediately for red flags requiring urgent evaluation: progressive neurologic deficits, bowel/bladder dysfunction (cauda equina syndrome), suspected infection, malignancy, or history of cancer 3, 4
• Assess psychosocial risk factors that predict chronic disability: depression, catastrophizing behaviors, fear-avoidance beliefs, and work-related stress 3
• Do NOT order imaging (MRI, CT, X-ray) without red flags present - degenerative changes correlate poorly with symptoms and imaging does not improve outcomes in nonspecific mechanical back pain 3, 5

First-Line Nonpharmacologic Treatment (Start Here)

Exercise Therapy - The Cornerstone

• Implement a supervised, individualized exercise program incorporating stretching and strengthening - this produces the best outcomes with moderate-quality evidence showing 10-point improvements on a 100-point pain scale 1, 2
• Motor control exercises specifically targeting coordination and strength of spinal-supporting muscles provide sustained benefits 2
• Programs should be tailored, supervised, and include both stretching and strengthening components 1

Activity Modification

• Advise the patient to remain active and continue ordinary activities within pain limits - those who maintain activity recover faster than those prescribed bed rest 3, 5
• Explicitly prohibit bed rest - it causes deconditioning, muscle atrophy, and worsens long-term outcomes 3, 5, 2
• Modify aggravating positions (forward bending, prolonged sitting) but maintain overall activity levels 4

Heat Therapy

• Apply superficial heat for 20-30 minutes, 3-4 times daily using heating pads or heat wraps 3, 2
• Heat provides moderate pain relief at 5 days and improved disability at 4 days 2, 3
• Combining heat with exercise provides greater pain relief than exercise alone 2

Additional Effective Nonpharmacologic Options

• Spinal manipulation by appropriately trained providers (chiropractor, osteopath, or physical therapist) provides small to moderate short-term benefits 1, 2
• Acupuncture shows moderate effectiveness for chronic low back pain 1
• Massage therapy demonstrates moderate effectiveness 1, 2
• Yoga (particularly Viniyoga-style) shows moderate superiority over self-care with sustained benefits at 26 weeks 1, 2
• Cognitive-behavioral therapy or mindfulness-based stress reduction should be considered, particularly given the >1 year duration suggesting psychological factors may be contributing 1, 2

Second-Line Pharmacologic Treatment (If Nonpharmacologic Insufficient After 4-6 Weeks)

First-Line Medications

• NSAIDs (ibuprofen 400mg every 4-6 hours, maximum 3200mg daily) are the preferred first medication choice, providing superior pain relief compared to other oral medications - approximately 10 points better on a 100-point scale 5, 3
• Assess cardiovascular and gastrointestinal risk factors before prescribing - NSAIDs carry CV thrombotic, GI bleeding, and renal risks 5, 3
• Use the lowest effective dose for the shortest duration necessary 5

Second-Line Medications (If NSAIDs Inadequate)

• Duloxetine is the preferred second-line agent when NSAIDs provide inadequate response, particularly if neuropathic pain components exist 5, 2
• Tricyclic antidepressants provide pain relief for chronic pain with neuropathic components 5, 2
• Tramadol is an alternative second-line option 2

Short-Term Adjuncts for Severe Pain

• Skeletal muscle relaxants (cyclobenzaprine) can be added for short-term use (7-14 days maximum) if severe pain with muscle spasm persists 5, 3
• Do NOT extend muscle relaxant use beyond 1-2 weeks - no evidence supports longer duration and sedation risks increase 5

Critical Pitfalls to AVOID

• Do NOT prescribe systemic corticosteroids - they are no more effective than placebo for low back pain 5, 3, 1
• Do NOT order routine imaging without red flags - it does not improve outcomes and may lead to unnecessary interventions 5, 3
• Do NOT recommend prolonged bed rest - it causes deconditioning and worsens symptoms 5, 2, 3
• Do NOT perform epidural injections, facet joint injections, radiofrequency ablation, or trigger point injections for nonspecific axial spine pain - strong evidence shows these do not improve morbidity, mortality, or quality of life 2
• Do NOT use TENS - it shows no benefit compared to sham TENS 2

When to Refer

• Consider referral to multidisciplinary pain management if pain persists despite optimized nonpharmacologic and pharmacologic therapy over 3-6 months 2, 3
• The American College of Physicians suggests considering specialist consultation after a minimum of 3 months to 2 years of failed nonsurgical interventions, though given this patient has already had >1 year of symptoms, referral at 3-6 months of optimized treatment is reasonable 1
• Immediate specialist consultation required for red flags: progressive neurological deficits, cauda equina syndrome, suspected infection, or malignancy 2, 3

Patient Education and Expectations

• Provide reassurance that chronic mechanical low back pain typically improves with activity rather than rest 2
• Set realistic expectations: nonpharmacologic therapies typically produce small to moderate benefits (10 points on 100-point scale), with effects on function generally smaller than effects on pain 2
• Extended medication courses should be reserved only for patients showing continued benefits without major adverse events 5, 1