Persistent Lower Back Pain

Managing Persistent Low Back Pain

The management of persistent low back pain in the primary care setting may be challenging. Some patients require referral to a multidisciplinary pain center where various approaches such as cognitive-behavioral therapy (CBT), patient education, exercise, and other strategies can be combined to help restore function. There are few controlled clinical trials that provide evidence-based recommendations for the management of persistent low back pain.

Nonpharmacologic Management

To prevent muscle deconditioning and to increase activity, exercise therapy is recommended and there is evidence that intensive exercise programs can reduce pain and restore function.^9-11 Physical therapy is often prescribed for persistent low back pain; while short-term benefit is reported, long-term effectiveness has not been demonstrated.¹² There is evidence that exercise and multidisciplinary therapy is effective^13,14  and some evidence in favor of acupuncture¹⁵ and spinal manipulation.¹⁶ The effectiveness of other treatments such as transcutaneous electrical nerve stimulation (TENS), acupuncture, spinal manipulation, massage, and lumbar support has not been established. Cognitive-behavioral therapy may have some benefit for patients with persistent low back pain. Multiple sessions of CBT designed to modify patients’ behaviors, beliefs, and coping skills have been shown to reduce health care use and work absenteeism.¹⁷ There also is limited evidence that epidural steroid injections may help some patients.¹⁸ 

Pharmacologic Management

While analgesic agents (e.g., NSAIDS, opioids) have demonstrated benefit in the relief of acute low back pain,^19-21 their long-term use in the treatment of persistent low back pain has not been well studied in controlled clinical trials. If used long-term, an effort usually should be made to integrate analgesics into a broader program that includes nonpharmacologic therapies (exercise, CBT), and their effectiveness should be continually reassessed. Adjuvant analgesics, such as tricyclic antidepressants (TCAs), also may be useful in some patients.⁷ Data supporting the use of muscle relaxants are lacking evidence.²²

Pharmacologic Management Options Nonopioid analgesics (e.g., NSAIDs) Opioids Adjuvant Analgesics (e.g., tricyclic antidepressants, muscle relaxants) Trigger point injections