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.

General considerations for all patients with chronic low back pain

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

  • Type of exercise is likely not important, as no difference between regimens has been shown.17
  • Consider patient capabilities and preferences in determining the type of exercise.5

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 improve short-term function more than pain, especially immediately after treatment.33

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

  • Combining with other treatment options may improve effectiveness (e.g., exercise, massage, yoga).17

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.

  • Most data supporting use are in neuropathic pain for patients unable to take oral medications.22

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)

NSAIDs
(e.g., ibuprofen, naproxen)

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

  • Acetaminophen may be no more effective than placebo [Evidence Level B-1].5,17, However it may be worth a try in patients unable to take chronic NSIADS, due to its safety profile.

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

Second-line

Antidepressants

Selective norepinephrine reuptake inhibitors (SNRIs)

  • Consider duloxetine 30 to 60 mg once daily for patients who fail or can’t take NSAIDs:7,13,27
    • Especially patients with comorbid depression or anxiety.
    • Even for patients without a neuropathic pain component.
  • Limited data support venlafaxine 150 mg/day in patients with depression AND chronic low back pain.10
  • Other SNRIs have not been studied in low back pain (e.g., desvenlafaxine, levomilnacipran).

The following are NOT recommended due to lack of efficacy:5,6,17

  • Tricyclic antidepressants ([TCAs], e.g., amitriptyline).
  • However, may be recommended if back pain has neuropathic involvement.6,25
  • Selective serotonin reuptake inhibitors ([SSRIs], e.g., fluoxetine, sertraline).

Third-line

Gabapentin or pregabalin

Guidelines do not support the use of gabapentin or pregabalin for most patients with low back pain.5,6,21

  • May be considered with concomitant neuropathic pain or involvement.6,14
    • Gabapentin: 100 mg at bedtime, increased to 300 to 1,200 mg three times daily.6,14
    • Pregabalin: 25 mg at bedtime, increased to 75 to 300 mg twice daily.6

Skeletal muscle relaxants
(e.g., cyclobenzaprine)

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

  • No difference in pain control between opioids and NSAIDs.21

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.

  • Recovery from chronic pain may be four times less likely in patients receiving opioids, compared to nonusers.31

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.

  • Up to 50% of patients taking opioids for at least three months are still taking them five years later.8

Tramadol: titrate dose up slowly, max dose of 400 mg/day (300 mg/day elderly).6,29,30

  • Conversion to long-acting product can be considered once an effective dose has been established.6
  • Use caution combining with duloxetine, due to risk of serotonin syndrome.29,30

Injections

Epidural steroid injections

Data are inconclusive about the true benefit of epidural steroid injections for back pain.6,20

  • Avoid in patients without associated radiculopathy or sciatica.6,20
  • Can be considered for some patients with a neuropathic component to their pain (e.g., radiculopathy [weakness, numbness, difficulty controlling specific muscles], sciatica [pain or numbness runs down the leg]), as benefit is typically acute and not sustained.6,20
    • These may be patients who are unable to take (or do not benefit from) other options or who need to avoid use of opioids.6,20
  • Data do not support use in patients with spinal stenosis.6,20

Most common adverse events include: bleeding, local hematoma, pain.20

  • Serious adverse events are rare (e.g., infection, nerve damage).20

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.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

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

  1. 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.
  2. 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).
  3. 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).
  4. 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.
  5. 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).
  6. 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).
  7. Product information for Cymbalta. Lilly USA. Indianapolis, IN 46285. May 2020.
  8. Franklin GM. Opioids for chronic noncancer pain: a position paper from the American Academy of Neurology. Neurology 2014;83:1277-84.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Chang V, Gonzalez P, Akuthota V. Evidence-informed management of chronic low back pain with adjunctive analgesics. Spine J 2008;8:21-7.
  14. 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.
  15. Van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003;(2):CD004252.
  16. 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).
  17. 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.
  18. Saragiotto BT, Machado GC, Ferreira ML, et al. Paracetamol for low back pain. Cochrane Database Syst Rev 2016;(6):CD012230.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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).
  26. Duke Integrative Medicine. Mindfulness based stress reduction. https://www.dukeintegrativemedicine.org/programs-training/public/mindfulness-based-stress-reduction/. (Accessed April 20, 2021).
  27. Product monograph for Cymbalta. Eli Lilly Canada. Toronto, ON M5X 1B1. March 2021.
  28. Haroutiunian S, Drennan DA, Lipman AG. Topical NSAID therapy for musculoskeletal pain. Pain Med 2010;11:535-49.
  29. Product information for Ultram. Janssen Pharmaceuticals. Titusville, NJ 08560. March 2021.
  30. Product monograph for Apo-tramadol. Apotex. Toronto, ON M9L 1T9. May 2020.
  31. 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.
  32. 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).
  33. Mu J, Furlan AD, Lam WY, et al. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev 2020;(12):CD013814.
  34. 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.
  35. 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]