Management of Chronic Back Pain

Initial Nonpharmacologic Treatment Approach

The American College of Physicians recommends initiating nonpharmacologic treatment with exercise therapy, multidisciplinary rehabilitation, acupuncture, yoga, cognitive behavioral therapy, or spinal manipulation as first-line therapy for chronic back pain lasting more than 10 years, reserving pharmacologic options only for inadequate responders 1
Exercise therapy should be the cornerstone, with programs incorporating individual tailoring, supervision, stretching, and strengthening showing the best outcomes for 2-18 months 1, 2
Multidisciplinary rehabilitation demonstrates strong evidence for improving both pain and function for 4 months to 1 year 4, 5
Acupuncture provides moderate-quality evidence for pain relief in chronic cases 1, 2
Yoga shows moderate effectiveness for chronic back pain 1, 2
Cognitive behavioral therapy or progressive relaxation offers relief lasting 4 weeks to 2 years 1, 2
Spinal manipulation by appropriately trained providers demonstrates small to moderate benefits 1, 2
Massage therapy provides moderate effectiveness for chronic pain 1, 2

The American Society of Anesthesiologists emphasizes the importance of conducting a thorough evaluation focusing on pain characteristics, psychosocial evaluation, functional assessment, and previous treatment history before initiating treatment 4, 5
Pain characteristics should include location, quality, intensity, temporal patterns, aggravating/relieving factors, and associated motor/sensory/autonomic changes 4, 5
Psychosocial evaluation should screen for anxiety, depression, anger, psychiatric disorders, coping mechanisms, impact on activities of daily living, sleep disturbance, and aberrant behaviors 4, 5, 6

The American College of Physicians recommends considering medications only after inadequate response to nonpharmacologic therapy, with NSAIDs as first-line pharmacologic therapy, followed by tramadol or duloxetine as second-line therapy, and opioids only as last resort 1
Skeletal muscle relaxants show moderate evidence for short-term relief but are not recommended for chronic use beyond acute exacerbations 1, 2
Gabapentin has small benefits for radiculopathy specifically, but insufficient evidence for nonspecific back pain 2
Systemic corticosteroids show no benefit over placebo and should be avoided 2
Benzodiazepines carry risks of abuse, addiction, and tolerance, and should be used only time-limited courses if necessary 2

The American Society of Anesthesiologists strongly recommends developing a long-term approach with periodic follow-up evaluations as part of the overall treatment strategy, with the goal of effectively reducing pain while improving function and rehabilitation 4, 5
Multidisciplinary programs should be used whenever available, rather than single-modality treatments 4, 5