Treatment of Chronic Low Back Pain

Nonpharmacologic Treatments

The American College of Physicians recommends nonpharmacologic treatments, including exercise therapy, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation as the initial approach for patients with chronic low back pain 1, 2, 3
Exercise therapy shows good evidence of moderate efficacy and should be a cornerstone of treatment for chronic low back pain 4
Multidisciplinary rehabilitation combining physical, psychological, and educational interventions demonstrates effectiveness, particularly when intensive 1, 3
Acupuncture provides modest effectiveness for pain relief 1, 2
Mindfulness-based stress reduction shows moderate-quality evidence for improvements in pain and function 5, 4
Cognitive behavioral therapy demonstrates good evidence of moderate efficacy 4
Tai chi results in moderate pain improvement compared with wait-list controls 5
Yoga (particularly Iyengar yoga) results in moderately lower pain scores and improved function compared with usual care 5
Massage therapy shows moderate effectiveness for chronic low back pain 4
Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 4

The American College of Physicians recommends NSAIDs as first-line pharmacologic therapy for patients who have had an inadequate response to nonpharmacologic therapy 1, 3
Tramadol or duloxetine should be considered as second-line therapy 1, 3
Opioids should only be considered as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks 1, 3
Tricyclic antidepressants (such as amitriptyline) and serotonin-norepinephrine reuptake inhibitors should be used as part of a multimodal strategy 6

Prescribe a structured exercise program tailored to patient capabilities 1, 4
Consider adding complementary approaches based on patient preference (yoga, mindfulness, tai chi) 5, 4
Implement cognitive-behavioral therapy to address psychosocial factors 5, 4
Continue effective nonpharmacologic treatments and add NSAIDs as first-line pharmacologic therapy if inadequate response after 4-6 weeks 1, 3, 4
Consider referral for multidisciplinary rehabilitation if inadequate response after 4-6 weeks 1, 3
Add tramadol or duloxetine as second-line pharmacologic therapy if still inadequate response 1, 3
Consider tricyclic antidepressants (starting with low doses, e.g., amitriptyline 10-25mg at bedtime) if still inadequate response 6
Consider opioids only after thorough discussion of risks and benefits if persistent severe pain despite above measures 1, 3

Avoid routine imaging for nonspecific low back pain as it does not improve outcomes and may lead to unnecessary interventions 4
Bed rest is contraindicated and can worsen outcomes 4, 7
The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate (5-20 points on a 100-point scale) and generally short-term 8
Effects on function are generally smaller than effects on pain 8
Transcutaneous electrical nerve stimulation (TENS) shows no difference compared to sham TENS for pain intensity or function 7
Lumbar supports have not shown clear benefits for chronic back pain 7
Systemic corticosteroids have not shown greater efficacy than placebo 4