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.