Nonpharmacologic Therapy

While some pharmacologic treatment modalities have shown small to moderate efficacy in alleviating acute and subacute low back pain, the majority of patients will improve over time.  Thus, current recommendations suggest that clinicians select nonpharmacologic therapies prior to instituting the use of pharmacologic agents.7  Specific nonpharmacologic therapies that have proven efficacious in treating acute and/or subacute low back pain include the use of superficial heat,8 massage,9 acupuncture,10 and spinal manipulation.11 If nonpharmacologic therapies do not improve pain or if a patient desires treatment with pharmacologic agents, there are a few drug categories that have proven efficacy in decreasing pain and improving functional ability.

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Pharmacological Therapy

Studies indicate that a majority of pharmacologic treatment modalities currently used for acute and subacute low back pain have shown little to small effect on patients’ pain levels and functional abilities.7 However, 2 categories of drugs — nonsteroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) — have demonstrated evidence for improving the quality of life for patients with acute or subacute low back pain.7

Research has demonstrated that when compared with placebo, patients taking NSAIDs demonstrated improvement in pain intensity12 and a small improvement in functional ability.13 No significant changes were identified to indicate that one NSAID was superior to another in head-to-head trials.  In similar studies, patients taking SMRs also reported improved pain relief when compared with those taking placebo.14

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Chronic Low Back Pain

Nonpharmacologic and pharmacologic therapies have been identified for the management of chronic low back pain (Table 2).

Table 2. Nonpharmacologic and Pharmacologic Treatment for the Management of Chronic Low Back Pain

Nonpharmacologic Therapy

In patients with chronic low back pain, the American College of Physicians recommends initial treatment to include nonpharmacologic therapies as the first-line option because they are affiliated with fewer harms to the patient as compared with pharmacologic therapies.7 Several nonpharmacologic therapies have demonstrated improvement in pain intensity and functional ability in patients with chronic low back pain. Moderate-quality evidence supports the use of exercise,15 multidisciplinary rehabilitation,16 acupuncture,17 and mindfulness-based stress reduction18 to assist in decreasing pain associated with chronic back low pain and increasing patient functional abilities.  Additional nonpharmacologic therapies recommended in the treatment of chronic low back pain but supported by low-quality evidence include  tai-chi,19 yoga,20 motor control exercises,21 progressive relaxation therapy,22 electromyography biofeedback,22 low-level laser therapy,23 cognitive behavioral therapy,22 and spinal manipulation.24