Treatment of Chronic Low Back Pain
Full update May 2021
Treatment of back pain that lasts beyond twelve weeks can be challenging. The chart below reviews evidence-based nondrug and drug therapy options in the treatment of chronic back pain. See our chart, Treatment of Acute Low Back Pain, to review drug and nondrug options for acute low back pain.
Medication or Intervention |
Comments |
NONDRUG THERAPY: Nondrug therapy is recommended first-line for chronic low back pain.17 A variety of options exist, and different patients may prefer or benefit from different techniques or interventions. |
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General considerations for all patients with chronic low back pain |
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Remain active9,17,19 |
Avoid bedrest.2,6,9,16 Continue normal activities to the extent possible.5 |
Evidence-based
educational materials1,9 |
Inexpensive.1 Supplements/reinforces verbal
information from prescriber.1 |
Medium-firm
mattress1 |
Firm mattress less likely to help.1 |
Weight loss6 |
Obesity is associated with low back pain.6,12 Efficacy of weight loss for chronic low
back pain unknown.6 |
Smoking cessation11 |
Smokers have a higher pain intensity score and higher risk of back pain.11 Evidence is conflicting,6 but some data show that quitting smoking is associated with improved pain [Evidence Level B-3].11 |
Evaluate
psychosocial factors2,9 |
Use regular follow-up to evaluate, and provide an expectation of return to work and
normal activities.2,5 |
First-line interventions |
|
Exercise6,17,19 |
Exercise may provide small improvements in pain and function.17,19
If unsupervised exercise worsens pain, therapist involvement may be necessary.6 Water exercise (e.g., aqua-jogging) may relieve pressure and provides a low-impact option for exercise. |
Acupuncture1,2,17,19,32 |
May provide moderate improvement in pain and function, when added to usual care.19,32
May provide better pain relief compared to NSAIDs [Evidence level B-2].17 |
Multidisciplinary rehabilitation (includes physical therapy as part of rehabilitation)1,17,19 |
May provide moderate improvements in pain and small improvements in function.19 May be beneficial for significant functional impairment/work refusal.1,6 May reduce the need for short-term
disability and increase likelihood of returning to work.19 |
Mindfulness-based stress reduction (e.g., meditation)17,19 |
Helps patients with awareness and to develop techniques to more effectively handle stress and pain.26 May provide small improvements in pain and
function.17 |
Other interventions to consider |
|
Spinal
manipulation (e.g., chiropractic adjustments)17,19 |
May provide small improvements in pain (not enough data to evaluate impact on function).19 Combine with exercise or psychological therapies (e.g., cognitive behavioral therapy, biofeedback).5
|
Yoga6,17,19 |
May provide small to moderate improvements in pain and function.19,32,34 More effective for short-term relief (e.g., 12 to 24 weeks) compared to long-term (e.g., 52 weeks).19 Most data support Vini yoga or Iyengar yoga types.6 Instructor with experience working with
patients with low back pain may prevent further injury.6 |
Progressive
muscle relaxation1,17 |
May provide moderate improvements in
pain and function.17 |
Massage1,2,17,19 |
May provide small improvements in pain and function.19 More effective for short-term relief (e.g., 12 weeks), compared to long-term (e.g., 52 weeks).19 Combine with education and exercise to
improve effectiveness.2 |
Tai Chi17,19 |
May provide moderate improvement in pain and small improvements in function.17 May decrease pain more than some other forms of exercise (e.g., jogging).17 |
Cognitive-behavioral
therapy and/or Biofeedback9,17 |
Use in combination with exercise therapy.5 May provide moderate improvements in
pain, but no effect on function.17. |
Laser therapy17 |
May provide small improvements in pain
and function.17 |
Operant therapy17 (e.g., behavioral exercises) |
May provide small improvements in pain, but no effect on function.17 |
Don’t rely on the following for relief |
|
Kinesiology tape |
Data are conflicting. Some studies find no difference in pain control compared to placebo in adults with chronic low back pain.24 Other reviews find improved pain relief with kinesiology taping compared to other physical techniques (e.g., physical therapy, acupuncture).35 May consider for pregnancy-related low back pain, when oral medications are limited.23 |
Lidocaine (topical) |
Data are lacking for low back pain, WITHOUT a neuropathic component.
See our chart, Topicals for Pain Relief, for more on lidocaine and other topical pain products. |
Transcutaneous electrical nerve stimulation (TENS) devices |
No difference in pain control comparing an active TENS device to an inactive sham TENS device.19 |
PHARMACOTHERAPY |
|
First-line (Newer guidelines NO longer recommend acetaminophen first-line.5,9,17) |
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NSAIDs
|
NSAIDs are more effective than acetaminophen (3,000 mg total daily dose) for back pain (e.g., ibuprofen up to 800 mg three times daily).1,6,9,18
Avoid NSAIDs in chronic renal disease, hypertension, heart failure, high GI or CV risk.2-4 Use lowest NSAID dose for shortest time necessary to minimize side effects.1,5 Current data do not support the use of topical NSAIDs in chronic low back pain.28 Consider using a PPI (e.g., omeprazole, lansoprazole) with NSAIDs to reduce GI risk.1,5,6
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Second-line |
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Antidepressants |
Selective norepinephrine reuptake inhibitors (SNRIs)
The following are NOT recommended due to lack of efficacy:5,6,17
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Third-line |
|
Guidelines do not support the use of gabapentin or pregabalin for most patients with low back pain.5,6,21
|
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Skeletal
muscle relaxants |
Not recommended for most patients with chronic low back pain due to lack of evidence.9,21 May be considered only “as-needed,” for acute flare-ups.6,9 No proof they are more effective than NSAIDs.15 High incidence of central nervous system adverse effects (e.g., sedation).15 Avoid in patients at risk of falls (e.g., elderly).2 Avoid benzodiazepines due to risk of
abuse, dependence, and tolerance.1 |
Opioids, including tramadol |
Avoid in most patients with chronic back pain.5,6,9
May be considered for severe, disabling pain uncontrolled with an NSAID.1 Weigh the risks of adverse effects (e.g., nausea, constipation, sedation), abuse, and misuse against benefit.
Watch for diversion and abuse; consider chronic pain contract.2 Principles of good prescribing suggest using the lowest effective dose for the shortest time needed.
Tramadol: titrate dose up slowly, max dose of 400 mg/day (300 mg/day elderly).6,29,30
|
Injections |
|
Epidural steroid injections |
Data are inconclusive about the true benefit of epidural steroid injections for back pain.6,20
Most common adverse events include: bleeding, local hematoma, pain.20
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Abbreviations: CV = cardiovascular; GI = gastrointestinal NSAID = nonsteroidal anti-inflammatory drug; PPI = proton pump inhibitor.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
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B |
Inconsistent or limited-quality patient-oriented evidence.* |
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C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]
References
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.
- Intermountain Healthcare. Care process model. Primary care management of low back pain. August 2014. https://intermountainhealthcare.org/ext/Dcmnt?ncid=522579081. (Accessed April 20, 2021).
- Choosing Wisely. Painkiller choices with kidney or heart problems. August 2012. http://www.choosingwisely.org/patient-resources/painkiller-with-kidney-or-heart-problems/. (Accessed April 20, 2021).
- Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation 2007;115:1634-42.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline 59. Updated December 11, 2020. https://www.nice.org.uk/guidance/NG59. (Accessed April 20, 2021).
- Toward Optimized Practice. Evidence-informed primary care management of low back pain. 3rd edition. Revised 2017. https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/LBP-guideline.pdf. (Accessed April 20, 2021).
- Product information for Cymbalta. Lilly USA. Indianapolis, IN 46285. May 2020.
- Franklin GM. Opioids for chronic noncancer pain: a position paper from the American Academy of Neurology. Neurology 2014;83:1277-84.
- Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated review. Eur Spine J 2018;27:2791-2803.
- Rej S, Dew MA, Karp JF. Treating concurrent chronic low back pain and depression with low-dose venlafaxine: an initial identification of “easy-to-use” clinical predictors of early response. Pain Med 2014;15:1154-62.
- Behrend C, Prasarn M, Coyne E, et al. Smoking cessation related to improved patient-reported pain scores following spinal care. J Bone Joint Surg Am 2012;94:2161-6.
- Shiri R, Karppinen J, Leino-Arjas P, et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010;171:135-54.
- Chang V, Gonzalez P, Akuthota V. Evidence-informed management of chronic low back pain with adjunctive analgesics. Spine J 2008;8:21-7.
- Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012;344:e497.
- Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003;(2):CD004252.
- North American Spine Society. Five things physicians and patients should question. Choosing Wisely. Updated April 8, 2019. https://www.choosingwisely.org/societies/north-american-spine-society/. (Accessed April 20, 2021).
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166:514-30.
- Saragiotto BT, Machado GC, Ferreira ML, et al. Paracetamol for low back pain. Cochrane Database Syst Rev 2016;(6):CD012230.
- Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med 2017;166:493-505.
- Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med 2015;163:373-81.
- Chou R, Deyo R, Friedly J, et al. Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med 2017;166:480-92.
- Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162-73.
- Kaplan S, Alpayci M, Karaman E, et al. Short-term effects of kinesio taping in women with pregnancy-related low back pain: a randomized controlled trial. Med Sci Monit 2016;22:1297-301.
- Luz Junior MA, Sousa MV, Neves LA, et al. Kinesio taping is not better than placebo in reducing pain and disability in patients with chronic non-specific low back pain: a randomized controlled trial. Braz J Phys Ther 2015;19:482-90.
- National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacologic management in non-specialist settings. Updated September 22, 2020. https://www.nice.org.uk/guidance/CG173/chapter/1-Recommendations. (Accessed April 20, 2021).
- Duke Integrative Medicine. Mindfulness based stress reduction. https://www.dukeintegrativemedicine.org/programs-training/public/mindfulness-based-stress-reduction/. (Accessed April 20, 2021).
- Product monograph for Cymbalta. Eli Lilly Canada. Toronto, ON M5X 1B1. March 2021.
- Haroutiunian S, Drennan DA, Lipman AG. Topical NSAID therapy for musculoskeletal pain. Pain Med 2010;11:535-49.
- Product information for Ultram. Janssen Pharmaceuticals. Titusville, NJ 08560. March 2021.
- Product monograph for Apo-tramadol. Apotex. Toronto, ON M9L 1T9. May 2020.
- Sjogren P, Gronbak M, Peuckmann V, Ekholm O. A population-based cohort study on chronic pain: the role of opioids. Clin J Pain 2010;26:763-9.
- North American Spine Society. Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of low back pain. https://painmed.wpengine.com/wp-content/uploads/2020/12/LowBackPain.pdf. (Accessed April 20, 2021).
- Mu J, Furlan AD, Lam WY, et al. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev 2020;(12):CD013814.
- Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain (review). Cochrane Database Syst Rev 2017;(1):CD010671.
- Sheng Y, Duan Z, Qu Q, et al. Kinesio taping in treatment of chronic non-specific low back pain: a systematic review and meta-analysis. J Rehabil Med 2019;51:734-40.
Cite this document as follows: Clinical Resource, Treatment of Chronic Low Back Pain. Pharmacist’s Letter/Prescriber’s Letter. May 2021. [370535]