Treatment
- noninvasive therapies with efficacy for chronic LBP include
- brief educational interventions, typically with advice to remain active
- exercise therapy
- spinal manipulation
- CBT (recommended by most guidelines as second-line therapy)
- massage therapy
- percutaneous nerve stimulation (PENS)
- acupuncture
- spa therapy
- oral pharmacologic treatments
- acetaminophen suggested as first-line therapy but insufficient evidence to determine efficacy
- nonsteroidal anti-inflammatory drugs (NSAIDs) recommended in most guidelines and may reduce pain in chronic LBP
- opioids
- may have short-term efficacy in chronic LBP but associated with adverse effects
- long-term efficacy data lacking
- weak opioids typically recommended in patients unresponsive to other therapies
- benzodiazepines (risk of adverse effects unclear)
- nonbenzodiazepine muscle relaxants have insufficient evidence
- antidepressants
- duloxetine (magnitude of benefit unclear)
- other antidepressants (including tricyclic antidepressants and SSRIs) may not reduce pain in patients with nonspecific LBP
- some herbal medicines (Devil’s claw, white willow bark, topical capsaicin) appear effective in short-term trials
- epidural steroid injections may provide short-term pain relief in patients with both
- lumbosacral radicular pain or neurogenic claudication
- imaging-confirmed nerve root involvement
- epidural nonsteroid injections
- may have higher positive response rate than nonepidural injection in adults with back or neck pain
- limited evidence to support any surgical or destructive procedure for treatment of chronic LBP including
- spinal fusion surgery
- disk replacement surgery
- radiofrequency denervation
- spinal cord stimulation
Consultation and referral
- refer to behavioral specialist and/or physical therapy for nonpharmacologic treatment modalities
- consider referral for epidural steroid injection in patients with radicular symptoms
- consider surgery referral in patients with
- significant functional disabilities
- pain lasting > 1 year not responding to multiple nonsurgical treatments
- pain consistent with an anatomic abnormality
- referral to pain management may be appropriate for patients with severe functional impairment and uncontrolled pain
Prognosis
- back pain appears to improve in first 6 weeks, moderate pain may persist with little difference at 1 year
- about 35% of patients with chronic LBP may be pain-free at 9 to 12 months
- many treatments for nonspecific LBP may have small analgesic effect
- psychosocial “yellow flag” findings predicting poor prognosis/long-term disability include
- anxiety
- depression
- feelings of uselessness
- irritability
- poor coping strategies
- pain-interrupted sleep
- history of sexual or physical abuse
- history of substance abuse
- inadequate social support
- older age
- overprotective environment
- occupational factors (such as expectation that pain will increase with work, pending litigation, problems with worker’s compensation claims
Prevention
- addition of daily exercise to education may prevent LBP in children
- no clear evidence of benefit for
- back belts or lumbar supports
- early behavioral intervention
- shoe insoles
- worksite back pain prevention program
Dr Drabkin is a senior clinical writer for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.
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