Low%20back%20pain Treatment
Principles of Therapy
- Includes treatment of symptoms and the underlying cause of low back pain
- Tailor treatment to patient’s condition and needs
Pharmacotherapy
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
Non-Pharmacological Therapy
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