Low Back Pain Management

Aka: Low Back Pain Management, Lumbar Disc Disease Management, Lumbar Back Pain Management, Lumbosacral Back Pain Management, Chronic Low Back Pain Management

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II. Management: General Measures

  1. Set early expectations of positive, gradual response to treatment
  2. Ice or heat applied to affected area
    1. Initial interval: 20-25 minutes per hour
    2. Later interval: three times daily
  3. Position of comfort
    1. Flexion relieves pressure on Posterior Columns
    2. Extension relieves pressure on anterior columns
  4. Body mechanics
    1. Ease transfers out of bed
    2. Ease moves to chair, car, toilet, and bathtub
  5. Stay active
    1. Early mobilization activities
      1. Slowly walk every 30 minutes
      2. Consider pool walking
    2. Improves outcomes
      1. Speeds recovery
      2. Reduces chronic Disability
      3. Reduces time off work
    3. Avoid exacerbating activities
      1. See Return to Work in Lumbar Back Pain
      2. Avoid prolonged standing or sitting
      3. Avoid forward flexion at waist (especially while lifting)
      4. Avoid prolonged bed rest (slows recovery)
        1. If absolutely needed, then limit to no more than 2 days
  6. Physical Therapy
    1. See Low Back Rehabilitation
    2. See Low Back Muscle Fusion Rehabilitation
    3. Consider if no improvement in 2 to 4 weeks
    4. Consider traction or inversion table
    5. Little added benefit in early referral for Acute Low Back Pain
      1. Fritz (2015) JAMA 314(14): 1459-67 [PubMed]
  7. McKenzie Method
    1. http://www.mckenzieinstitute.org/clinicians/
    2. Initial assessment by methodology trained PT and then individualized self treatment
      1. Rosedale (2014) J Orthop Sports Phys Ther 44(3): 173-81 [PubMed]
      2. Dunsford (2011) J Multidiscip Healthc 4:393-402 [PubMed]
    3. Self-Directed McKenzie Method Book is available
      1. https://www.amazon.com/Treat-Your-Back-Robin-McKenzie/dp/0987650408
  8. Corset
    1. Stabilizes spine but does not immobilize back
    2. May allow patient to continue to work
    3. Reduces Exercise benefit of daily activities
  9. Massage
    1. No affect on pain, functional status or mobility
  10. Resources
    1. Robin McKenzie (2011) Treat your Own Back
      1. https://www.amazon.com/Treat-Your-Back-Robin-McKenzie/dp/0987650408
    2. Ten stretches for Low Back or Midback Pain (Bob and Brad)
      1. https://www.youtube.com/watch?v=dfMiuFsM1o8
    3. Back Pain Program (Bob and Brad)
      1. https://www.youtube.com/watch?v=FrVfVupelJY&list=PL8l32k1r15l73-noQNhmHILi3BvtMpvU7

III. Management: Acute Pain Control

  1. NSAIDs
    1. Effective for short-term symptomatic relief
      1. Griffin (2002) Am Fam Physician 65(7):1319-21 [PubMed]
    2. Opioid Analgesics and Muscle relaxants do not offer significant additional benefit
      1. Naproxen alone was as effective as when combined with an Opioid or Cyclobenzaprine
        1. Friedman (2015) JAMA 314(15): 1572-80 [PubMed]
  2. Acetaminophen
    1. Dose: 1000 mg orally twice daily (maximum 4000 mg/day)
    2. May have less benefit than other measures
      1. Reasonable low risk intervention (if within dosing limits) that may spare Opioids
    3. Mixed result in studies
      1. Some studies demontrate relief of musculoskeletal pain with Acetaminophen alone
        1. Gong (2019) Ann Emerg Med 74(4):521-29 [PubMed]
      2. Some studies demonstrate adjunctive benefit when combined with NSAIDs
        1. Bijur (2021) Ann Emerg Med 77(3):345-56 [PubMed]
      3. Some studies show little benefit in decreased pain and increased function in Acute Low Back Pain
        1. Machado (2015) BMJ 350:h1225 [PubMed]
      4. Not more effective than Placebo in Chronic Low Back Pain
        1. Williams (2014) Lancet 384(9954): 1586-96 [PubMed]
  3. Opioids
    1. Use sparingly for refractory Acute Low Back Pain
    2. Limit to very short course (risk of Opioid Misuse, Opioid Abuse and diversion)
    3. Patients improve faster without Opioids
    4. Not more effective than non-Opioid management in the first 6 weeks of Low Back Pain
      1. Jones (2023) Lancet 402(10398): 304-12 [PubMed]
  4. Lidocaine Patch (4% is over-the-counter)
    1. Applied for 12 of every 24 hours
    2. May offer transient relief in paraspinous pain
  5. Muscle relaxants or antispasmodics (Benzodiazepines and non-Benzodiazepines)
    1. Not recommended due to lack of benefit and increased adverse effects
      1. Cashin (2021) BMJ 374: n1446 [PubMed]
    2. Efficacy studies
      1. May reduce Acute Low Back Pain
      2. Does not impact outcome
      3. Minimal benefit over NSAIDs alone
      4. No benefit over Placebo in Chronic Low Back Pain
    3. Entire class acts centrally and causes sedation
      1. Greatest benefit may be at night to assist sleep
    4. Valium does not add benefit over Naproxen alone for Low Back Pain
      1. Friedman (2017) Ann Emerg 70(2): 169-76 +PMID: 28187918 [PubMed]
  6. Systemic Corticosteroids (variable evidence)
    1. Efficacy
      1. Variable benefit over NSAIDs and increased risk of adverse effects
      2. May reduce radicular pain in the short term
      3. No significant benefit in Acute Low Back Pain without radiculopathy due to Herniated disc
      4. No significant benefit in spinal stenosis related pain
      5. No benefit in Chronic Low Back Pain
    2. Protocols
      1. Single Parenteral dose of Dexamethasone 10 mg IV/IM may offer short-term relief
        1. Balakrishnamoorthy (2015) Emerg Med J 32(7):525-30 +PMID: 25122642 [PubMed]
      2. Some studies have suggested treating for seven day course on fast taper
      3. Some studies demonstrating efficacy have used a 2 week taper (Prednisone 60, 40 then 20 mg)
    3. References
      1. Chou (2022) Cochrane Database Syst Rev (10): CD012450 [PubMed]
      2. Goldberg (2015) JAMA 313(19):1915-23 +PMID:25988461 [PubMed]
      3. Haley (2023) Am Fam Physician 107(3) +PMID: 36920810 [PubMed]

IV. Management: Spinal Manipulation

  1. Manipulation may improve Low Back Pain in up to 85% of patients when 2 criteria met
    1. Acute Low Back Pain less than 16 days AND
    2. No symptoms distal to the knee
    3. Fritz (2005) BMC Fam Pract 6(1): 29 [PubMed]
  2. Some studies have shown efficacy in acute and Chronic Low Back Pain
    1. (2005) Best Pract Res Clin Rheumatol 19(4):639-54 [PubMed]
  3. Equivalent efficacy to other conservative measures
    1. Analgesics
    2. Physical therapy
    3. Back school
    4. Assendelft (2003) Ann Intern Med 138:871-81 [PubMed]
    5. Rubinstein (2019) BMJ +PMID: 30867144 [PubMed]

V. Management: Chronic Pain Control - Effective Non-Medication Measures

  1. Exercises and Therapy
    1. Effective Exercise includes aerobic Exercise, pool Exercise, pilates, tai chi, structured walking
    2. Exercise is the only Chronic Low Back Pain intervention with sustained pain relief
      1. Decreases pain and improves function (esp. in the first 6 to 12 weeks)
      2. Kolber (2021) Can Fam Physician 67(1):e20-30 [PubMed]
      3. Lindberg (2021) Cochrane Database Syst Rev (9): CD009790 [PubMed]
    3. Perform daily back Exercises
    4. Consider back school
      1. Intensive low back educational sessions may be very effective
      2. Engers (2008) Cochrane Database Syst Rev (1): CD004057 [PubMed]
    5. Consider multidisciplinary treatment program (including Cognitive Behavioral Therapy)
      1. Kamper (2015) BMJ 350:h444 [PubMed]
    6. Consider Acupuncture
      1. Growing evidence for benefit, especially in Chronic Low Back Pain
      2. See Acupunture for related studies
      3. Best used in combination with other standard measures
    7. Prescribed Walking Program (at least 4 days weekly)
      1. As effective as physical therapy in improved function and decreased pain
      2. Hurley (2015) Pain 156(1): 131-47 [PubMed]
  2. Cognitive Behavior Therapy
    1. Improves pain and Disability in Chronic Low Back Pain
    2. Methods to improve quality of life
      1. Relaxation Technique
      2. Mindfulness
      3. Behavioral activation and exposure
    3. Modifying attitude toward pain reduces Disability
      1. Normal functioning possible despite back pain
      2. Pain does not cause harm, and activity may hurt
      3. Goal is return to function, not eliminating pain
      4. Dramatically reduces time to return to work
      5. Staal (2004) Ann Intern Med 140:77-84 [PubMed]
  3. Acupuncture
    1. Not immediately effective for short-term pain
    2. May be effective in reducing pain in the first year, but does not appear effective at 2 years
    3. Mu (2020) Cochrane Database Syst Rev 12(12):CD013814 +PMID: 33306198 [PubMed]
  4. Yoga (or Qi Gong)
    1. Does not consistently improve outcomes (Disability, quality of life, pain) compared with other activities
    2. However some studies have shown short and longterm efficacy in Chronic Low Back Pain
      1. Cramer (2013) Clin J Pain 29(5):450-60 [PubMed]
  5. Dry Needling
    1. Short term improvements in pain
    2. Lara-Palomo (2024) Clin Rehabil 38(3):347-360 +PMID: 37700695 [PubMed]
  6. TENS Unit
    1. Mixed results in studies
    2. Some studies show improvement in short term pain and function
      1. Jauregui (2016) Surg Technol Int 28: 296-302 [PubMed]
      2. Wu (2018) Reg Anesth Pain Med 43(4): 425-33 [PubMed]
    3. Other studies show no significant benefit over Placebo
      1. Khadikar (2008) Cochrane Database Syst Rev (4):CD003008 [PubMed]
      2. Paley (2021) Medicina 57(10): 1060 [PubMed]

VI. Management: Chronic Pain Control - Effective Medication Measures

  1. NSAIDs
    1. Less effective for long-term pain relief (avoid regular use >4 to 12 weeks)
    2. Risk of Peptic Ulcer Disease and Renal Injury
  2. Serotonin Norepinephrine Reuptake Inhibitor
    1. Cymbalta (Duloxetine) appears more effective than Placebo in Chronic Low Back Pain
    2. Consider with comorbid depression or anxiety
    3. Sklijarevski (2009) Eur J Neurol 16(9): 1041-8 [PubMed]
  3. Tricyclic or Tetracyclic Antidepressant (e.g. Amitriptyline, Nortriptyline)
    1. Mechanism related to Norepinephrine reuptake inhibition and may reduce back pain symptoms
    2. However, mIxed results in studies and not consistently recommended
      1. High rate of adverse effects (NNH 12)
      2. Moderate quality evidence that TCAs have little effect on pain intensity
    3. SSRI medications do not appear to be effective
      1. Staiger (2003) Spine 28:2540-5 [PubMed]
  4. Anticonvulsants
    1. Consider for neuropathic, radicular pain
      1. Found to be more effective than Placebo
      2. However limited evidence in Low Back Pain and not found effective in Sciatica
    2. Efficacy
      1. Mixed results, with some studies showing specific medication benefits (see below)
      2. Other studies have shown no benefit
        1. Enke (2018) CMAJ 190(26): E786-93 [PubMed]
    3. Medications
      1. Pregabalin (Lyrica)
      2. Gabapentin (Neurontin)
        1. Yildirim (2009) J Back Musculoskelet Rehabil 22(1): 17-20 [PubMed]
      3. Topiramate (Topamax)
        1. Muehlbacher (2006) Clin J Pain 22(6): 526-31 [PubMed]
  5. Onabotulinum Toxin A (Botox)
    1. Effective in Low Back Pain with radiculopathy
    2. De Andres (2010) Reg Anesth Pain Med 35(3): 255-60 [PubMed]

VII. Management: Chronic Low Back Pain Control - Ineffective or Mixed Efficacy Measures (when compared with Placebo)

  1. Acetaminophen
    1. See above
  2. Trigger Point Injection
    1. No proven benefit in Low Back Pain
      1. However, dry needling has shown benefit (see above)
    2. Modalities
      1. Local Anesthetic injections
      2. Spray or ice followed by stretch
  3. Radiofrequency Ablation (Denervation)
    1. Heat used to destroy nerves from painful regions (Lumbar medial branch, sacral lateral branch)
    2. May reduce pain for up to 36 months
      1. Chappell (2020) BMJ Open 10(7):e035540 +PMID: 32699129 [PubMed]
    3. Does not improve function or quality of life in the longterm
      1. Maas (2015) Cochrane Database Syst Rev 2015(10):CD008572 +PMID: 26495910 [PubMed]
  4. Epidural Corticosteroid Injection
    1. Efficacy
      1. May slightly reduce pain and improve function in the short-term in patients with radiculopathy
      2. No longterm benefit (pain, Disability, function) over Placebo in Chronic Low Back Pain
      3. Choi (2013) Int J Technol Assess Health Care 29(3): 244-53 [PubMed]
      4. Friedly (2014) N Engl J Med 371(1):11-21 [PubMed]
      5. Manchikanti (2014) Pain Physician 17(4): E489-501 [PubMed]
      6. Novak (2008) Arch Phys Med Rahabil 89(3): 543-52 [PubMed]
      7. Oliveira (2020) Cochrane Database Syst Rev (4):CD013577 [PubMed]
    2. Indications (if used despite lower efficacy)
      1. Lumbar Disc Herniation with moderate to severe radiculopathy
      2. Symptoms should be refractory to 2-3 weeks of conservative therapy
    3. Preparation
      1. Typically follows MRI
      2. However classic symptoms and signs may direct ESI to best level when imaging is not possible
      3. Performed under fluoroscopy to optimize injection site
      4. Discuss significant neurologic deficits with Spine Surgery prior to epidural steroid injection
  5. Spinal Cord Stimulators
    1. Do not appear to improve pain, function or health-related quality of life at 6 months
    2. May slightly improve back function and reduce Opioid use at 12 months (with maximal medical management)
    3. Complications include infection, lead migration, spine or nerve injury and need for revision surgery
    4. Traeger (2023) Cochrane Database Syst Rev 3(3):CD014789 +PMID: 36878313 [PubMed]
  6. Other measures without benefit over Placebo in Chronic Low Back Pain
    1. Lumbar supports
    2. Mechanical traction
    3. Facet Joint Injections offer no proven benefit
    4. Sacroiliac Joint Injections are rarely indicated
    5. Lidocaine Patch (4% or 5%)
      1. Hashmi (2012) Mol Pain 8:29 [PubMed]
    6. Opioids and Tramadol should be avoided for chronic back pain as much as possible
      1. Try to save Opioids for acute exacerbations refractory to other measures

VIII. Management: Lumbar Surgery

  1. See Lumbar Surgery
  2. Background
    1. More than 1.2 Million back surgeries are performed in the U.S. per year
    2. Elective low back surgery for refractory symptoms is not a universal panacea (see efficacy below)
      1. A majority of Chronic Low Back Pain patients are either not better or are worse after surgery
      2. Other non-surgical measures are preferred in elective cases
  3. Common surgical procedures
    1. Spinal Fusion
    2. Lumbar Disc Replacement
    3. Diskectomy
    4. Spinal Laminectomy and Spinal decompression
  4. Surgery Indications
    1. Urgent and Emergent
      1. Cauda Equina Syndrome (emergent surgery)
      2. Progressive Motor Weakness (urgent surgical evaluation)
      3. Spinal Infection (e.g. Diskitis, Spinal Osteomyelitis, Spinal Epidural Abscess)
      4. Unstable Lumbar Vertebral Fracture
      5. Spinal Malignancy
    2. Progressive spinal stenosis with nerve impingement
    3. Progressive Spondylolisthesis
    4. Lumbar Disc Herniation with unilateral Sciatica (consistent imaging and exam) >4 months
      1. Bailey (2020) N Engl J Med 382(12): 1093-102 +PMID: 32187469 [PubMed]
    5. Disabling Low Back Pain impacting quality of life for >1 year (poor surgical efficacy)
      1. Refractory to conservative measures
      2. Persistent functional Disability
  5. Efficacy of Elective Spine Procedures (non-urgent and non-emergent causes)
    1. Overall only 33% of patients are satisfied with improvement after surgery (33% feel worse)
      1. Chou (2009) Spine 34(10):1066-77 +PMID: 19363457 [PubMed]
    2. No significant benefit for Spinal Fusion after 13 years in degenerative non-radicular Chronic Low Back Pain
      1. Hedlund (2016) Spine J 16(5): 579-87 [PubMed]
      2. Mirza (2007) Spine 32(7): 816-23 [PubMed]
  6. References
    1. Roth (2022) Am Fam Physician 105(6): 667-70 [PubMed]

IX. Prognosis: Factors associated with Chronic Pain (more factors increase risk)

  1. Background
    1. Of those with Acute Low Back Pain, 20% will still have functional deficit at 3 months
  2. Affect
    1. Anxiety Disorder
    2. Major Depression
    3. Feeling of Uselessness
  3. Behavior
    1. Adverse coping strategies
    2. Impaired sleep
    3. Passive role
  4. Beliefs
    1. Belief that pain is harmful and must be eliminated
  5. Social
    1. Drug Abuse, physical abuse or sexual abuse
    2. Poor social support
  6. Work
    1. Anticipating that pain will increase with work
    2. Pending litigation
  7. References
    1. Last (2009) Am Fam Physician 79(12):1067-1074. [PubMed]

X. Resources

  1. Spinal Stabilization Exercises and Spine Conditioning (AAOS)
    1. https://orthoinfo.aaos.org/globalassets/pdfs/2017-rehab_spine.pdf
  2. Low Back Pain Fact Sheet (NINDS)
    1. https://www.ninds.nih.gov/sites/default/files/migrate-documents/low_back_pain_20-ns-5161_march_2020_508c.pdf
  3. Low Back Pain Guidelines (VA)
    1. https://www.healthquality.va.gov/guidelines/pain/lbp/

XI. References

  1. Atlas (2001) J Gen Intern Med 16:120-31 [PubMed]
  2. Herndon (2015) Am Fam Physician 91(10): 708-14 [PubMed]
  3. Maharty (2024) Am Fam Physician 109(3): 233-44 [PubMed]
  4. Tulder (2002) Am Fam Physician 65(5):925-8 [PubMed]
  5. Will (2018) Am Fam Physician 98(7):421-8 [PubMed]

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