Low%20back%20pain Treatment

• Includes treatment of symptoms and the underlying cause of low back pain
• Tailor treatment to patient’s condition and needs

Analgesics (Non-Opioid)

• Eg Paracetamol (Acetaminophen), Aspirin, Capsaicin (topical)
• Recommended 1st-line treatment for acute, subacute and chronic low back pain
• Also recommended for patients with chronic low back pain with or without radicular pain, especially if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated
• A weaker analgesic but with less adverse effects compared to NSAIDs 
• Paracetamol with weak opioid is recommended as alternative when NSAIDs or Paracetamol alone is ineffective in controlling pain
• Aspirin is now used infrequently for the treatment of chronic pain and inflammation
  • May be used for patients with concomitant cardiovascular risk factors
• Capsaicin (topical) is recommended for acute and subacute low back pain; may also be used for flare-ups of chronic back pain
  • Capsicum plaster may be used as an adjunct for short-term basis in patients with chronic low back pain

Anticonvulsants

• Eg Carbamazepine, Gabapentin, Pregabalin, Topiramate
• Topiramate may be used for patients with chronic low back pain as last-line therapy
  • Used in patients with concomitant anxiety or depression disorders
• Carbamazepine is a treatment option for patients with radicular pain unresponsive to traditional treatments
• Gabapentin may also be used for patients with radicular pain syndrome with severe neurogenic claudication and limited walking distance
• Off-label use for chronic radicular and neuropathic pain

Antidepressants

• Eg mixed serotonin and norepinephrine reuptake inhibitors/SNRIs (Duloxetine, Venlafaxine); tricyclic antidepressants/TCAs (Amitriptyline, Desipramine, Doxepin, Imipramine, Maprotiline, Nortriptyline)
• Treatment option for pain alleviation in patients with acute, subacute and chronic low back pain

Benzodiazepines

• Eg Diazepam
• May be used for acute, subacute, and chronic low back pain for patients unresponsive to 1st-line treatments
  • Off-label use as a muscle relaxant in patients with subacute or chronic low back pain 
• May also be given to patients with painful radiculopathy
• Sedative, anxiolytic, and antiepileptic that acts on gaba-aminobutyric acid (GABA)
• Should only be used  for <1 week
• Avoid combination therapy with an opioid due to an increased risk of overdose compared with opioid monotherapy

Glucocorticoid Injections

• Epidural steroid injections may be used by specialists for patients with acute or subacute severe radicular pain, spinal stenosis, sacroiliitis unresponsive to 2-6 weeks of non-invasive treatment
• Should not be used as monotherapy
• Further studies are needed to conclude the efficacy of steroid injections for chronic low back pain

Local Anesthetics

• Eg Lidocaine patches
• Further studies are needed to prove the efficacy of Lidocaine patches in chronic low back pain

Muscle Relaxants (Non-Benzodiazepine)

• Eg Baclofen, Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Eperisone, Metaxalone, Methocarbamol, Orphenadrine, Tizanidine
• Used as 2nd-line treatment for moderate-severe acute or subacute low back pain unresponsive to NSAID therapy, and for patients with acute exacerbations of chronic low back pain
• Moderately effective compared to placebo for short-term pain relief of acute low back pain
• Also recommended for patients with acute radicular pain syndrome
• Should only be used for <4 weeks
• Caution should be observed when using these as they may cause drowsiness, dizziness, addiction, liver disorders, and other adverse effects

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Eg acetic acid derivatives (Aceclofenac, Diclofenac, Etodolac, Indomethacin, Sulindac); coxibs (Celecoxib, Etoricoxib); anthranilic acid derivatives (Meclofenamate, Mefenamic acid); oxicam derivatives (Meloxicam, Piroxicam, Tenoxicam); propionic acid derivatives (Ibuprofen, Ketoprofen, Loxoprofen, Naproxen); other NSAIDs (Nimesulide)
• Recommended as 1st-line pharmacological treatment for acute, subacute and chronic low back pain
  • Provides moderate short-term analgesia for acute low back pain
  • Moderately more effective for chronic low back pain than placebo
• Useful also for patients with acute lumbosacral radiculopathy 
• Non-selective NSAIDs have increased risk for gastrointestinal complications
• COX-2-selective NSAIDs produce lesser gastrointestinal symptoms compared to non-selective NSAIDs
  • Not recommended for patients with known cardiovascular risk factors 
• Topical NSAIDs are also an effective option for mild cases
• May be used in combination with proton pump inhibitors (PPIs)
  
  • Have gastroprotective properties against the adverse effects of NSAIDs

Opioid Analgesics

• Eg Buprenorphine, Codeine, Diamorphine, Dihydrocodeine, Fentanyl, Oxycodone, Tramadol
• Recommended for severe acute, subacute and chronic low back pain and radiculopathy not controlled by NSAIDs and non-opioid analgesics
• Some studies argue that the efficacy of opioid analgesics is similar to that of NSAIDs and non-opioid analgesics but should only be used if former treatments were ineffective
• Tramadol is recommended as 2nd-line pharmacological therapy for chronic low back pain 
• Weak opioids help relieve pain and disability in patients with non-specific chronic low back pain
• Duration of treatment should be limited to <2 weeks to decrease the risk of dependency and the potential for misuse and abuse

Exercise

• Recommended 1st-line non-pharmacological treatment for chronic low back pain 
• A tailored exercise regimen for up to 8 times in 12 weeks may be beneficial
• Stretching, strengthening, stabilization, directional and aerobic exercises are recommended for patients with acute, subacute, and chronic low back pain
  • Aerobic exercise is recommended in patients with non-specific low back pain to improve pain, disability and mental health
• Aquatic exercise may be advised in selected patients with subacute and chronic low back pain
• Gradually transitioning into moderate-higher stress exercises may improve outcome 
• Low-stress exercises may be started during the 1st 2 weeks of acute low back pain attack
  
  • Effectively prevents debilitation due to inactivity 
• Yoga is recommended for patients with acute, subacute, or chronic low back pain of >1 year
  • Several studies have shown that viniyoga is superior to traditional exercises, self-care educational books, and medications for the management of chronic low back pain
• Studies suggest tai chi resulted in improvement of moderate pain 
• May also help improve pain and function in patients with radicular low back pain

Functional Restoration

• Involves physical conditioning, work conditioning, or work hardening programs
• May be considered in patients with chronic low back pain when with cognitive-behavioral techniques

Physical Modalities

Electrical Nerve Stimulation

• Eg transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS)
• Recommended as an adjunct therapy for patients with chronic non-specific low back pain and chronic radicular pain, and sciatica
• TENS utilizes continuous electrical impulses to deliver temporary pain relief
  
  • Uses a small battery-operated device that delivers the impulses via surface electrodes
  • Not recommended for acute low back pain
• PENS uses slim needles inserted into the skin to be able to deliver low-level electrical stimulation to target tissues/organs
  
  • Targets pathological tissues via dermatomal levels
• PENS is moderately superior to TENS when based on pain relief and functional outcome

Low-Level Laser Therapy (LLLT)

• May be considered for temporary pain alleviation in acute low back pain if combined with exercise
• Provides moderate pain relief in patients with acute or subacute low back pain when coupled with NSAID therapy
• Studies showed pain relief and improved function in chronic low back pain with LLLT compared with sham laser
• Utilizes dermal application of electromagnetic energy with laser wavelengths ranging from 632-904 nm

High-Intensity Laser Therapy (HILT)

• Effective for short-term pain relief when combined with exercise

Thermotherapy

• Application of hot and/or cold compress/wrap provides short-term relief of acute low back pain
• Low-tech cryotherapies may be helpful for acute, subacute, and chronic low back pain
• Radiofrequency ablation may provide improvement in pain relief, intake of pain medications, and quality of life in patients with chronic lumbar facet joint back pain
• Intradiscal electrothermal therapy (IDET) has been found to be effective for treating discogenic low back pain

Ultrasound

• Usually done together with other physical modalities  
• Beneficial effect is derived from the heating of the deep tissues  
• A few studies have shown it to be effective for chronic low back pain

Spinal Manipulation/Spinal Manipulative Therapy (SMT)

• May be considered for acute, subacute, and chronic low back pain only after serious pathology has been ruled out
• When used for acute low back pain, therapy should be given within the 1st month of appearance of symptom
  • Effective for short-term pain management
• Studies showed that manipulation/mobilization of the cervical/thoracic spine for patients with chronic low back pain may be effective for temporary symptom alleviation and improvement of function
• 12-18 sessions are suggested for better treatment effects

Other Options

Acupuncture

• May be considered for persistent non-specific low back pain and for some patients with moderate-severe low back pain and chronic low back pain
• Considered to be more effective for temporary relief of chronic low back pain compared to nontreatment and sham acupuncture
• A maximum of 10 sessions in 12 weeks is suggested

Dry Needling/Needlestick

• May help alleviate pain coming from a specific trigger point in patients with chronic low back pain
• Studies showed that dry needling exhibits better pain relief for chronic low back pain when given in conjunction with other interventions

Massage

• Moderately helps provide short-term pain relief in patients with acute, subacute and chronic low back pain compared to other non-pharmacological interventions
  • Massage coupled with exercise and/or education is superior in efficacy compared when done alone when used in patients with subacute to chronic low back pain

Spa

• May help patients with chronic low back pain

Psychological/Behavior Therapies

• Eg cognitive behavior therapy, electromyography (EMG) biofeedback, relaxation training (eg mindfulness-based stress reduction), hypnosis, fear avoidance belief training (FABT)/kinesiophobia
• May help patients with issues regarding emotional, behavioral and cognitive aspects of dealing with pain
• When combined with other therapies, psychological therapy is highly recommended for patients with chronic low back pain
• Further studies are needed to prove the efficacy of biofeedback for patients with acute low back pain

Alternative Therapies

• Eg devil’s claw (Harpagophytum procumbens) root, white willow bark (Salix alba), cayenne (Capsicum frutescens), comfrey (Symphytum officinale) root extract, and topical lavender essential oil
• Studies show moderate benefit from herbal therapies