Version July 2025
INTRODUCTION —
Up to 84 percent of adults have low back pain at some point in their lives [1,2]. While rapid improvement in pain and disability are the norm in acute low back pain, as symptoms persist beyond four weeks, the likelihood of a self-limited back pain episode declines over time [3-5]. Though meaningful improvement is still possible, a subset of these patients may go on to develop chronic back pain that persists beyond 12 weeks.
The management of subacute and chronic low back pain is typically divided into the following categories:
●Nonpharmacologic treatment – For all patients for symptom relief and improved function
●Pharmacologic treatment – For selected patients with persistent symptoms
●Nonsurgical interventional treatment – For selected patients with persistent symptoms despite conservative management, including nonpharmacologic and pharmacologic treatment
●Surgical treatment – For patients with severe or progressive weakness or signs of cauda equina syndrome and in carefully selected patients with persistent, disabling symptoms and significantly impaired quality of life refractory to nonsurgical approaches
The general approach to management of nonspecific subacute and chronic low back pain is presented in this topic, including initial care, guidance for acute flares and severe or refractory symptoms, and indications for specialty care. Further detail on nonsurgical interventional treatment and surgical treatment for severe or refractory symptoms is discussed separately:
●(See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
●(See "Subacute and chronic low back pain: Surgical treatment".)
The treatment of acute low back pain and the evaluation of low back pain are also discussed separately:
●(See "Treatment of acute low back pain".)
●(See "Evaluation of low back pain in adults".)
DEFINITIONS —
Patients with nonspecific low back pain are categorized into three groups according to the duration of symptoms:
●Acute low back pain – Pain lasting up to four weeks
●Subacute low back pain – Pain lasting between 4 to 12 weeks
●Chronic low back pain – Pain lasting greater than 12 weeks
A glossary of terms used in the discussion of low back pain is presented in the table (table 1).
Criteria used to classify the magnitude of benefits for the most commonly reported outcomes (pain relief or improvement in function) are presented in a table (table 2).
INITIAL MANAGEMENT
Pretreatment evaluation — Patients with back pain who have not previously had an evaluation for an underlying back pain etiology should undergo a detailed back pain evaluation before a presumptive diagnosis of "nonspecific low back pain" is considered. (See "Evaluation of low back pain in adults".)
Risk assessment for chronic, disabling pain — We perform a brief psychosocial risk assessment for all patients with nonspecific subacute or chronic low back pain. By risk-stratifying patients, clinicians can prioritize higher-risk patients for additional interventions (eg, psychologic and mind-body therapies) while avoiding overtreatment in patients who have a high likelihood of recovery (ie, those for whom advice on self-care interventions and independent exercise may be sufficient) [6].
●Risk factors for chronic low back pain – Known factors associated with the development of chronic low back pain and low back pain-related disability include pre-existing psychologic conditions, somatization, maladaptive pain coping behaviors (eg, fear avoidance or catastrophizing), high level of functional impairment, the presence of other types of chronic pain, job dissatisfaction or stress, and dispute over compensation issues [7,8]. Other risk factors include obesity, smoking, and the receipt of medical care inconsistent with low back pain management guidelines [6].
●Risk factors and prognosis – The prognosis for subacute low back pain depends on the presence of risk factors. When present, risk factors predict the risk for chronic, disabling low back pain more reliably than physical examination findings, severity, or duration of pain. In one inception cohort study of 5233 patients with acute low back pain, 32 percent of patients transitioned to chronic low back pain at six-month follow-up [6]. The transition to chronic low back pain was associated with high-risk designation using a validated prognostic tool that assessed pain, disability, coping, and psychologic conditions (adjusted odds ratio 2.45, 95% CI 2.00-2.98). There was also a positive linear association between the risk of developing chronic low back pain and the number of exposures to care that deviated from established guidelines (eg, early receipt of opioids, imaging, and subspecialty referral).
●Risk stratification tools – Several structured evaluation tools are available to assist in this evaluation [7,9,10].One such approach, the STarT Back (Subgroups for Targeted Treatment) tool, facilitates the categorization of low back pain patients into those with a low, medium, and high risk of developing persistent, disabling back pain [11-14]. In one study, the proportion of patients with persistent, disabling back pain at six-month follow-up was 22, 62, and 80 percent for the low-, medium-, and high-risk groups, respectively (95% CI 18-25 for low-risk, 57-67 for medium-risk, and 75-85 for high-risk groups) [11]. This tool has been validated as a predictive tool, and in a randomized trial in the United Kingdom, a risk-stratified approach using STarT Back was more effective than usual care in managing patients with low back pain of varying duration [12].
While the use of an adapted STarT Back approach was not associated with improvement in patient outcomes in the subsequent Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial in the United States [15], these results are difficult to interpret due to study methodology. In the MATCH trial, clinicians in the intervention group received education on the STarT Back approach but were not required to use the tool or recommend treatments based on risk stratification. Only half the study patients were evaluated with the STarT Back tool, and when used, treatment recommendations were not uniformly guided by the STarT Back category. Therefore, the study's mixed results reflect the challenges of implementing a risk-stratified approach in varied clinical settings; because the trial design did not require use of the STarT Back approach, it does not offer much additional insight into the efficacy of risk-stratified treatment when used as originally developed.
Self-care advice — Self-care advice for all patients with nonspecific subacute or chronic low back pain should include the following:
●Maintain activity as tolerated – Initial advice should stress the importance of maintaining activity as tolerated for all patients with subacute and chronic low back pain, regardless of duration or severity [16,17]. Patients who require a period of bed rest due to severe symptoms should be encouraged to return to usual activities as soon as possible.
In a systematic review of trials in a mixed back pain population, advice to remain active (in addition to providing specific advice on the most appropriate exercise) was effective in reducing pain and work disability for patients with chronic low back pain [18]. Because different measures were used across trials, the magnitude of benefit could not be assessed.
●Self-care education – For patients who are amenable, we provide advice on self-care, including stretching and graded activity. As examples:
•(See "Patient education: Low back pain in adults (The Basics)".)
•(See "Patient education: Low back pain in adults (Beyond the Basics)".)
•(See "Patient education: Back exercises (The Basics)".)
Self-care education books based upon evidence-based guidelines (such as The Back Book) are an effective and inexpensive method for supplementing clinician-provided information and advice [19,20]. Several randomized trials have shown self-care education books to be similarly effective, or only slightly inferior, to interventions with higher direct costs, such as supervised exercise, massage, acupuncture, and spinal manipulation [21-24].
●Heat (or ice) – We advise the use of heat (heating pad on low setting for 20 minutes every two hours) followed by gentle stretching as tolerated for patients with subacute back pain and during flares in patients with chronic low back pain. We do not generally advise the use of ice or cool packs, but if a patient finds symptomatic relief with their use, there is no contraindication.
In a systematic review of nine trials including 1100 patients with acute and subacute low back pain, the application of superficial heat was superior to no heat for short-term improvement in pain [25]. There was insufficient evidence to determine the effects of cold packs.
There are no high-quality data on the use of superficial heat or cold in the treatment of chronic low back pain. If either provides symptomatic relief during a flare, however, they can be used for short periods of time.
Initial treatment options — The following treatments may be used as monotherapy or in combination, depending on patient interest and motivation.
Exercise therapy — For all patients with nonspecific subacute and chronic low back pain, we recommend participation in an exercise program or movement-based therapy. Exercise therapy improves function and alleviates pain symptoms in patients with low back pain [26].
●Independent versus supervised programs
•Patients at low risk for disabling back pain – Individual patient factors can guide the selection of independent versus supervised programs; those who are motivated will likely do well with an independent exercise program, while others may benefit from participation in a more structured or supervised program.
•Patients at high risk for disabling back pain – The following patients may benefit more directly from a supervised exercise program:
-Patients with subacute low back pain with risk factors for chronic low back pain (see 'Risk assessment for chronic, disabling pain' above)
-Patients with chronic low back pain (>12 weeks duration)
-Patients with severe symptoms limiting independent participation in exercise
The support offered by supervised exercise programs may provide reassurance and ultimately facilitate the patient's progression to more independent exercise. (See 'Risk assessment for chronic, disabling pain' above and "Exercise therapy for low back pain", section on 'Formulating an individual exercise plan'.)
Participation in multidisciplinary rehabilitation programs that combine exercise, psychologic therapy, and other patient-specific approaches may be of additional benefit in this high-risk patient group. (See 'Multidisciplinary rehabilitation' below.)
●Exercise modalities – There is a wide range of exercise and other movement-based therapies commonly used in patients with subacute and chronic low back pain. Such exercise programs include motor control exercise (also known as specific stabilization exercise), core strengthening (eg, abdominal and trunk extensor), flexion/extension movements, directional preference (eg, McKenzie exercises), general physical fitness, aerobic exercise, Pilates, exercise programs with a mind-body component (eg, yoga and tai chi), and functional restoration programs. These, along with studies of their efficacy, are described separately. (See "Exercise therapy for low back pain", section on 'Selected exercise modalities'.)
Most exercise therapies appear to be similarly effective, and the decision of which type of exercise to recommend should be based upon practical considerations, including local availability, patient preferences and abilities, insurance coverage, and previous history of success (or lack of success) with a particular exercise program. Further details on exercise program selection are discussed separately. (See "Exercise therapy for low back pain", section on 'Counseling and anticipatory guidance' and "Exercise therapy for low back pain", section on 'Formulating an individual exercise plan'.)
Nonopioid analgesics — Adjunctive pharmacologic therapy may provide symptomatic relief of pain and facilitate participation in active therapies, including exercise and psychologic treatments. Supporting data on the duration of medication treatment are limited. Thus, we use the lowest effective dose and frequency, favoring an "as needed" over a "standing" dosing schedule, and attempt to taper and discontinue these analgesic medications when possible.
Although nonpharmacologic therapy is generally preferred over pharmacologic therapy, they are commonly used together in clinical practice. For patients that prefer nonpharmacologic therapy, referral for any combination of exercise, psychologic, or passive therapies is appropriate. (See 'Exercise therapy' above and 'Psychologic and mind-body therapies' below.)
●NSAIDs – The majority of patients with subacute or chronic low back pain will have already tried nonsteroidal anti-inflammatory drug (NSAID) therapy (either of their own initiative or upon prior clinician recommendation/prescription) during the acute or subacute phase. Patients who have not yet tried NSAID therapy warrant a trial of NSAIDs for pain relief, provided there are no contraindications [17]. Options and doses are provided in the table (table 3). NSAID therapy is further managed as follows [27]:
•If NSAIDs are effective in controlling symptoms, we continue them without adding additional pharmacologic therapy.
•If NSAIDs are only partially effective in controlling symptoms and additional pain control is required, we continue NSAIDs but add additional pharmacologic therapy with selected skeletal muscle relaxants, duloxetine, and other agents. We also offer referral for psychologic and other adjunctive treatments. (See 'Psychologic and mind-body therapies' below.)
•We do not use NSAIDs for chronic therapy if they were ineffective in managing subacute low back pain symptoms.
NSAIDs are associated with side effects (eg, gastrointestinal, kidney, and cardiovascular), and risk factors for complications should be assessed before recommending. (See "Nonselective NSAIDs: Overview of adverse effects".)
●Acetaminophen – For patients who are unable to take NSAIDs (ie, due to allergy or other contraindications), acetaminophen is a reasonable alternative. We use acetaminophen 650 mg orally every six hours as needed (maximum 3 grams per 24 hours) for most adults, although we use a lower total daily dose for older adult patients and those with any hepatic impairment (table 3). We do not combine acetaminophen with NSAIDs.
Evidence supporting the use of acetaminophen for chronic low back pain is mostly indirect. In systematic reviews of patients with multisite osteoarthritis (not limited to the back), acetaminophen was more effective than placebo but was consistently inferior to NSAIDs for pain relief [28-30].
Acetaminophen overdose can lead to severe hepatotoxicity and is the most common cause of acute liver failure in the United States [31]. Other possible adverse effects that have been associated with acetaminophen include chronic kidney disease, hypertension, and peptic ulcer disease. Patients should be made aware of the safe total daily dose of acetaminophen and consider all sources of acetaminophen in both prescription and over-the-counter medications. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation".)
Psychologic and mind-body therapies — CBT or mind-body interventions, including mindfulness-based stress reduction (MBSR), biofeedback, and progressive relaxation, can help address psychosocial contributors to pain.
●Patient selection – Early referral for these therapies is appropriate for patients who have chronic low back pain; patients who are identified as high risk for chronic, disabling low back pain by risk assessment; and patients who express interest in nonpharmacologic treatment. Psychologic and mind-body therapies may be particularly useful in patients with significant functional impairment and who either exhibit maladaptive coping behaviors (fear avoidance, catastrophizing) or cannot participate in exercise. (See 'Risk assessment for chronic, disabling pain' above.)
CBT and mind-body therapy treatment options are not widely available to all patients, and not all patients are amenable to participating in these therapies. Patient expectations of benefit from treatment should be taken into consideration when choosing interventions, as they appear to influence outcomes. Other factors to consider when choosing among available therapies include prior response to treatments, cost, convenience, and local availability of skilled providers for specific therapies [32-34]. Studies of psychologic therapies delivered through telehealth and app-based programs suggest similar efficacy compared with conventional in-person interventions [35].
●Treatment modalities – These interventions can be prescribed individually, combined with supervised exercise programs, or coordinated through a multidisciplinary rehabilitation program.
•Cognitive-behavioral therapy – We prioritize CBT as a primary therapy in patients with higher-risk, subacute low back pain and chronic low back pain causing significant functional impairment.
CBT is a goal-oriented, problem-solving, psychotherapeutic approach where negative thinking patterns and coping behaviors are addressed, and it is widely used in the management of a variety of chronic pain syndromes. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Cognitive-behavioral therapy'.)
CBT improves both pain and disability in patients with low back pain. In a systematic review and meta-analysis including 23 studies and 3300 patients with subacute and chronic low back pain, CBT was superior to waitlist control, usual care, and guideline-based active treatment for improvement in both short- and long-term pain and reduction in disability [36]. Trials of CBT, including variations such as cognitive functional therapy and pain reprocessing therapy, have also shown benefits for chronic low back pain [37,38].
•Mindfulness-based stress reduction – We refer to MBSR programs, where available, as an adjunctive treatment for higher-risk patients with disabling chronic low back pain or as an alternative to CBT in patients who prefer MBSR.
MBSR is a mind-body relaxation technique designed to enhance a person's ability to relax, cope with stress, and help manage pain. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Mind-body therapies' and "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Meditation and mindfulness-based stress reduction'.)
In a meta-analysis of seven randomized controlled trials involving 864 patients with low back pain, MBSR modestly improved pain intensity and physical functioning compared with usual care [39]. In one of the included studies in which 340 adults with chronic low back pain were randomly assigned to receive either MBSR, CBT, or usual care, MBSR was found to be similar to CBT in reduction in pain and disability at 26 and 52 weeks [40].
Passive therapies for short-term symptom relief — Short-term interventions such as spinal manipulation, acupuncture, or massage may be considered for select patients with chronic low back pain or subacute low back pain with more severe symptoms or risk factors for chronicity. Because these "passive" treatments provide primarily short-term symptomatic improvement, we counsel patients to view them as an initial step toward subsequent participation in active therapies. The decision to refer and selection of interventions depends upon patient interest, cost, and the availability of skilled providers, as there are no data demonstrating the superiority of one over another [16].
Many of the studies evaluating the use of these treatments were performed either on patients with chronic low back pain or in mixed (combined subacute and chronic) back pain patient populations.
●Spinal manipulation – Spinal manipulation may have short-term benefits in the management of subacute and chronic low back pain. It is a form of manual therapy that involves the movement of a joint beyond its usual end range of motion but not past its anatomic range of motion. Spinal manipulation is most commonly performed by chiropractic providers; it is also offered by osteopathic clinicians and physical therapists. (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Types of manipulation'.)
A 2011 meta-analysis including 26 randomized trials of 6000 patients with chronic low back pain compared spinal manipulation with multiple interventions, including general practitioner care, analgesics, physical therapy, exercises, back school, massage, ultrasound, transcutaneous muscle stimulation, and pain clinic care [41]. Spinal manipulation had small short-term effects on pain reduction and improved functional status compared with the other interventions. Subsequent randomized trials support these findings of short-term benefits of spinal manipulation in patients with subacute and chronic low back pain [41-45]. In a 2018 meta-analysis, the combination of spinal manipulation plus other active treatments produced a small benefit on pain and function at 12 months compared with other active treatments alone [46].
Serious adverse events following lumbar spinal manipulation (such as worsening lumbar disc herniation or cauda equina syndrome) are possible but rare. (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Risks of spinal manipulation'.)
●Acupuncture – Clinical trials and meta-analyses have generally found acupuncture (an intervention consisting of the insertion of needles at specific, predetermined acupuncture points) is more effective than usual care for low back pain but may not be more effective than sham acupuncture (insertion of needles at non-acupuncture points or applying needles to acupuncture points but not actually inserting them) [47,48]. Benefit, when seen, is often within the first seven days of treatment.
In a meta-analysis of 33 clinical trials involving 8270 participants with chronic nonspecific low back pain, pain relief and functional outcomes were similar in patients treated with real and sham acupuncture procedures [48]. However, acupuncture was more effective for immediate pain relief when compared with no treatment (mean difference on the visual analog scale [range 0 to 100; 0 = no pain, 100 = worst pain] 20 points lower in the acupuncture group, 95% CI 16-24; four trials, 366 participants). In addition, back-specific functional status was higher in the acupuncture group (mean difference in the Hannover Functional Ability Questionnaire [range 0 to 100; 0 = disabled, 100 = full function] 12 points lower in the acupuncture group, 95% CI 7-16; five trials, 2960 participants).
It is unclear if the effectiveness of sham acupuncture derives from some attribute of the technique (eg, superficial needling in non-acupuncture points) or is solely a placebo effect. Further details regarding the procedure and clinical use of acupuncture are discussed separately. (See "Overview of the clinical uses of acupuncture".)
●Massage – There is limited evidence to support the long-term efficacy of massage therapy in the treatment of chronic low back pain, although interpretation and comparison of studies is hampered by differences in the comparator interventions, including types of massage, duration, and frequency of massage sessions.
A systematic review including 25 trials evaluated the effects of massage on patients with subacute and chronic low back pain [49]. Compared with patients receiving no other treatment, those receiving massage therapy had only short-term improvement in pain and function.
However, harms from massage treatment appear to be minimal, and some patients report symptomatic relief with massage. Thus, we feel it is a reasonable adjunctive short-term pain management option for those patients who are interested in pursuing massage treatment.
MANAGEMENT OF PERSISTENT OR SEVERE SYMPTOMS —
Patients with subacute and chronic low back pain with persistent symptoms or minimal improvement with initial treatment options may warrant additional pharmacotherapy or specialty referral. (See 'Initial treatment options' above.)
Skeletal muscle relaxants for short-term relief — For patients with subacute or chronic low back pain for whom nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen therapy is ineffective or inadequate, we suggest a trial of a nonbenzodiazepine skeletal muscle relaxant as adjunctive therapy for up to four weeks. Cyclobenzaprine or tizanidine are preferred because their mechanism of action is understood, they have undergone more rigorous studies than other skeletal muscle relaxants, and they don't have the abuse potential associated with certain skeletal muscle relaxants (eg, carisoprodol). These may be prescribed at bedtime initially, followed by use during the daytime or as a standing dose if needed and if the patient does not experience significant somnolence:
●Cyclobenzaprine – 5 to 10 mg orally three times daily as needed (with one of the doses take at bedtime to help with sleep)
●Tizanidine – 2 to 8 mg orally three times daily as needed
High-quality data on the use of skeletal muscle relaxants in patients with subacute and chronic low back pain are lacking, and the recommendation to use them in this patient population is based upon the efficacy of these medications in patients with acute low back pain [50-52]. In a systematic review, skeletal muscle relaxants were better than placebo for short-term improvement in pain in patients with acute low back pain, but there was insufficient evidence to determine whether they were effective for subacute or chronic low back pain [52].
These medicines have not been studied for long-term use and are associated with sedation and other adverse effects; therefore, we limit their initial trial to less than four weeks. Occasionally, we continue these medications for longer than four weeks, but only in situations where the medication is well tolerated, other treatment options have been ineffective, and the patient obtains benefit from their continued use. (See 'Long-term use of skeletal muscle relaxants' below and "Treatment of acute low back pain", section on 'Combination with muscle relaxants'.)
If longer-term therapy is needed, duloxetine or other serotonin-norepinephrine reuptake inhibitors (SNRIs) may be used. (See 'Longer-term pharmacologic options' below.)
Longer-term pharmacologic options — For patients with chronic low back pain in whom NSAID therapy is ineffective or inadequate and who require long-term pharmacologic therapy beyond four weeks, duloxetine, tricyclic antidepressants, and tramadol are commonly used [27]. In such patients, we continue to offer nonpharmacologic therapies as an adjunct or alternative to these pharmacologic options. (See 'Initial treatment options' above.)
Duloxetine — We use duloxetine as second-line pharmacologic therapy for patients with chronic low back pain in whom NSAID therapy is inadequate or ineffective. Duloxetine has some evidence of efficacy, carries approval by the US Food and Drug Administration for this indication, and does not have the potential for misuse associated with tramadol. The longer onset of action of duloxetine and other SNRIs limits their role in the treatment of acute or subacute back pain.
Duloxetine is started at 30 mg orally once daily and after one week is increased to 60 mg orally once daily if tolerated. Unlike the other analgesics discussed above, duloxetine must be taken every day, rather than "as needed."
In a 2021 meta-analysis including four randomized trials and over 1400 patients with chronic low back pain, duloxetine was more effective than placebo in reducing pain and disability at three months [53]. The degree of improvement in both measures was small and of uncertain clinical importance. However, the estimated benefits are similar to other treatments for chronic back pain, including first-line medications such as NSAIDs. Patients were more likely to discontinue duloxetine compared with placebo due to adverse effects.
Depression is common in patients with chronic low back pain, and as an antidepressant, duloxetine may have an additional indication for use in a patient with chronic low back pain and coexisting depression [54]. However, the analgesic effects of duloxetine are independent of depression. (See "Major depressive disorder in adults: Approach to initial management".)
Tricyclic antidepressants — Tricyclic antidepressants are an alternative to duloxetine, especially for those patients with pain symptoms that interfere with sleep or for those in whom duloxetine is ineffective or cost prohibitive. Tricyclic antidepressants are used to treat various other chronic pain syndromes and had previously been recommended for the treatment of low back pain, but their small and inconsistent benefits in studies of back pain may not outweigh their known side effects (most commonly drowsiness, dry mouth, and dizziness).
Adverse effects of the tricyclics may limit the tolerability of these medications, particularly at higher doses, and they should be used with caution in older patients. Examples of tricyclic antidepressants used in the management of chronic low back pain include:
•Amitriptyline – 25 to 75 mg orally once daily at bedtime
•Nortriptyline – 25 to 75 mg orally once daily at bedtime
•Desipramine – 50 to 150 mg orally once daily at bedtime
In a meta-analysis including six trials and almost 400 patients with chronic low back pain, tricyclic antidepressants were associated with benefits at three months similar to those observed with SNRIs. However, the degree of improvement was small and below the review's threshold for clinical importance [53]. Tricyclic antidepressants were not associated with adverse events or dropouts due to adverse events in the safety analysis.
Other pharmacotherapy — Tramadol, a drug with mixed opiate agonist and SNRI activity, carries the potential for misuse and dependency; therefore, we prioritize duloxetine and tricyclic antidepressants as first-line medications for chronic low back pain (see 'Duloxetine' above and 'Tricyclic antidepressants' above). For patients with persistent symptoms or contraindications to antidepressants, we prescribe tramadol similarly to other opioids, as below. (See 'Restricted use of opioids' below.)
Patients with severe or refractory symptoms may warrant additional pharmacologic therapy or specialty care, as discussed below. (See 'Management of disabling or refractory symptoms' below.)
Multidisciplinary rehabilitation — Multidisciplinary rehabilitation is a comprehensive program that combines graded exercise therapy with psychologic interventions.
●Indications – For patients who need more intensive therapy or for whom first-line active therapies (exercise, cognitive-behavioral therapy, or mindfulness-based stress reduction) are inadequate in managing pain and improving function, we refer to a multidisciplinary rehabilitation program if available. Local availability and insurance coverage for multidisciplinary rehabilitation programs are variable; therefore, we only refer patients to these programs if nonmultidisciplinary first-line therapies have been unsuccessful. Multidisciplinary rehabilitation may also be appropriate in patients who have severe functional impairment and risk factors for chronicity and in patients who do not improve with exercise alone who express interest in multidisciplinary rehabilitation.
●Treatment modalities – Multidisciplinary rehabilitation combines (at a minimum) an exercise and a psychologic intervention component provided by different health care professionals and can be effective in the management of patients with higher-risk, subacute low back pain and significant chronic low back pain. Intensity and content of multidisciplinary therapy vary widely. Multidisciplinary therapy focuses on functional improvement ("functional restoration") and may emphasize occupational aspects of rehabilitation.
●Evidence of benefit – In a systematic review of 41 trials, multidisciplinary rehabilitation that combined a physical component with a psychologic component and/or a social/work-targeted component was associated with slightly larger improvements in pain and function than usual care or nonmultidisciplinary physical treatments (eg, exercise therapy, physical modalities, manual therapy, education) [55]. Differences were approximately 0.5 points on a 0 to 10 point pain scale and 1.5 points on the Roland Morris Disability Questionnaire (both considered small differences) (table 2). Multidisciplinary treatment also increased the likelihood of return to work compared with nonmultidisciplinary physical treatments alone (odds ratio 1.87, 95% CI 1.39-2.53). There was no clear effect of intervention intensity (frequency and duration of therapies) on effectiveness of multidisciplinary rehabilitation.
●Referral considerations – Patients are more likely to benefit from multidisciplinary rehabilitation if they are highly motivated, as the regimens can be time consuming (eg, >20 hours per week). Referring clinicians should familiarize themselves with outcomes for specific programs prior to referral, given the cost and heterogeneity of quality among programs.
Multidisciplinary rehabilitation programs are usually coordinated by pain clinics or rehabilitation centers and may not be widely available in many communities. It is uncertain whether providing the components of multidisciplinary rehabilitation outside of a formal program is as effective as administering them through a coordinated program.
MANAGEMENT OF DISABLING OR REFRACTORY SYMPTOMS —
For patients with severe or refractory symptoms persisting beyond 12 weeks, the focus of care shifts toward reducing symptoms, maximizing coping, and preventing disability, rather than symptom resolution.
Medications for severe or refractory symptoms — For patients with persistent symptoms despite engagement with exercise therapy, cognitive-behavioral therapy or other psychologic therapy, and first-line adjunctive pharmacologic treatments, closely monitored long-term use of selected medications or combination therapy are additional therapeutic options. We reserve opioid therapy for selected patients who have persistent, disabling symptoms despite all other therapeutic attempts.
Long-term use of skeletal muscle relaxants — Skeletal muscle relaxants are typically recommended only for short-term, adjunctive therapy for up to four weeks, as studies on long-term use of skeletal muscle relaxants are lacking. However, in patients with refractory back pain for whom these medications were effective in the short term, the long-term use of a skeletal muscle relaxant alone or in combination, as below, may offer relief of symptoms while avoiding opioid use. We recommend similar options and dosing schedules as those recommended for short-term use. (See 'Skeletal muscle relaxants for short-term relief' above.)
Combination therapy — General principles of combination therapy include adding medications one at a time, starting with the lowest possible dose, and titrating up based on response. If no benefit is obtained with the addition of a medication, it should be discontinued before another medication is added. Patients should be monitored closely for adverse effects on combination regimens. Example combination regimens include:
●Nonsteroidal anti-inflammatory drugs (NSAIDs) with duloxetine 30 mg orally once daily, increased to 60 mg orally once daily after one week if tolerated (see 'Nonopioid analgesics' above and 'Duloxetine' above)
●Combination therapy with skeletal muscle relaxants:
•NSAIDs with a skeletal muscle relaxant (cyclobenzaprine 5 to 10 mg orally three times daily as needed, with one of the doses take at bedtime to help with sleep, or tizanidine 4 to 8 mg orally three times daily as needed). (See 'Nonopioid analgesics' above and 'Skeletal muscle relaxants for short-term relief' above.)
•Duloxetine 30 mg orally once daily, increased to 60 mg orally once daily after one week if tolerated, may be combined with a skeletal muscle relaxant, such as tizanidine 4 to 8 mg orally three times daily as needed. (See 'Duloxetine' above and 'Skeletal muscle relaxants for short-term relief' above.)
Tizanidine is preferred over cyclobenzaprine because of the possibility of additive serotonergic effects with cyclobenzaprine. (See "Serotonin syndrome (serotonin toxicity)".)
Restricted use of opioids — Opioids should not be used routinely for the management of chronic low back pain, given poor or modest efficacy and the potential for harm [17,56,57].
Tramadol — Tramadol is an opioid agonist that also inhibits the reuptake of serotonin and norepinephrine [58]. Tramadol may be used for patients who have not responded to initial therapy with other agents. (See 'Duloxetine' above and 'Tricyclic antidepressants' above.)
●Dosing – Tramadol can be taken either as a standing dose or "as needed." For instance, when therapy is initiated, we prescribe it to be taken "as needed" and subsequently adjust the dosing schedule according to the patient's response. We typically start at the lowest dose (eg, tramadol 25 to 50 mg orally every six or eight hours as needed), particularly in older adults and opioid-naïve patients. The dose may then be increased if necessary (eg, tramadol 50 to 100 mg orally every six hours as needed).
If a patient has constant symptoms, it can be prescribed to be taken on a standing schedule (eg, tramadol 50 mg orally every six hours); the frequency is then decreased or changed to an "as-needed" dosing schedule as symptoms improve.
We never use a long-acting tramadol preparation when initiating tramadol therapy because it complicates dose titration. In patients already on a stable, standing dosing schedule of short-acting tramadol, a long-acting tramadol preparation may be more convenient, but we do not routinely use it because it is generally more costly and not associated with improved pain relief or function.
●Contraindications and potential harms – Despite its classification as a "mixed-mechanism" agent, tramadol has weak mu opioid receptor affinity with associated misuse and dependency potential. Tramadol should be prescribed with caution in patients with a history of substance use disorder [58,59]. In addition, tramadol lowers the seizure threshold and carries a risk of serotonin syndrome, especially when combined with other serotonergic agents [60]. In such patients with refractory back pain, the longer-term addition of a skeletal muscle relaxant may be a better option than tramadol, although no trials to date have evaluated these medications for long-term use. (See 'Long-term use of skeletal muscle relaxants' above.)
●Limited evidence of benefit – Tramadol achieves moderate short-term pain relief compared with placebo in patients with low back pain; however, published trials are of short duration (2 to 13 weeks) and with methodologic limitations [27,51,61,62].
Other opioids
●Indications and contraindications – Opioid therapy is reserved for selected patients who have persistent, disabling symptoms despite all other therapeutic attempts, including nonsurgical interventional options and/or specialist evaluation. (See 'Patients with severe, chronic, nonspecific low back pain' below.)
Opioid use should be restricted to patients not highly vulnerable to drug dependence, misuse, or addiction, and only when the potential benefits outweigh the risks. When initiated, the lowest possible opioid dose should be used, and use should be monitored closely [27,63]. (See "Use of opioids in the management of chronic pain in adults", section on 'Evaluation of risk prior to initiating therapy' and "Use of opioids in the management of chronic pain in adults", section on 'Follow-up and monitoring during chronic opioid therapy'.)
●Limited evidence of efficacy – Systematic reviews and meta-analyses of opioid use in patients with chronic low back pain identified few high-quality and no long-term trials [57,64-67]. In the available trials, opioids produced only small, short-term improvements in pain and function when compared with placebo and had no benefit compared with NSAIDs or antidepressants. A long-term, randomized trial compared stepped therapy starting with opioids versus nonopioid medications in 240 Veterans Affairs patients with moderate to severe chronic back pain or hip or knee osteoarthritis [67]. At one year, there was no difference in pain-related function, while pain was slightly better in nonopioid-treated patients. In addition, patients treated with opioids experienced more negative side effects. It should be noted that in patients assigned to stepped therapy with nonopioid medications, opioids were permitted at later steps, but the doses used were very low.
●Potential harms – Studies of the use of opioids for chronic and subacute low back pain rarely quantify the risk of important harms, such as abuse or addiction, and have typically excluded patients at higher risk for these types of adverse events. In one systematic review, aberrant drug-taking behaviors were found in up to 24 percent of patients receiving opioids for low back pain, but most studies had important methodologic shortcomings, including poorly described or validated methods for identifying such behaviors [64]. (See "Risk of long term opioid use and misuse after prescription of opioids for pain".)
●Dosing and administration – Opioid prescribing is discussed separately. (See "Use of opioids in the management of chronic pain in adults", section on 'Choice of agent and dose'.)
If the patient achieves adequate symptom control, we attempt to discontinue the opioid entirely, though this is often not possible. (See "Use of opioids in the management of chronic pain in adults", section on 'Discontinuing therapy'.)
●Patients who are already on opioid therapy – For patients who are already taking long-term opioid therapy for chronic low back pain, we attempt to lower the morphine milligram equivalent dose by optimizing nonpharmacologic therapies and utilizing first-line pharmacotherapy. (See 'Nonopioid analgesics' above and 'Initial treatment options' above.)
Indications for imaging — Patients who have not improved after four to six weeks of conservative therapy and who did not receive imaging on initial evaluation should be re-evaluated. (See "Evaluation of low back pain in adults", section on 'Determining if imaging is indicated'.)
Patients without specific concerns and with stable or improving symptoms should continue with conservative therapy. If there is no improvement after 12 weeks, we image with a plain radiograph and consider referral for further evaluation and treatment. (See 'Indications for specialty care' below.)
Indications for specialty care — For patients with persistent, disabling symptoms who have exhausted nonpharmacologic and pharmacologic options described above, we refer for specialty care evaluation with surgical and/or interventional pain medicine specialists, as these patients may be candidates for nonsurgical interventional treatment or surgery. We typically obtain imaging prior to referral, as above, as interventional and surgical specialists may require imaging prior to their consultation. (See 'Indications for imaging' above.)
Surgery for severe or progressive neurologic symptoms — Regardless of back pain duration, patients who develop severe or progressive weakness or symptoms of cauda equina syndrome warrant urgent evaluation with a neurosurgeon or orthopedic surgeon with experience in back surgery. (See "Subacute and chronic low back pain: Surgical treatment", section on 'Indications for spinal surgery' and "Lumbar spinal stenosis: Treatment and prognosis", section on 'Surgical treatment'.)
Patients with subacute or chronic radiculopathy — Chronic radicular pain conditions are most commonly due to disc herniation or spinal stenosis with or without degenerative spondylolisthesis. In these patients, there is no evidence that early referral for surgery, in the absence of severe or progressive neurologic deficits, improves outcomes for lumbar disc prolapse with radiculopathy or symptomatic spinal stenosis [68,69]. The presence of mild foot drop or other minor motor deficits due to lumbar disc prolapse with radiculopathy is not an absolute indication for surgery because many such patients will recover with nonsurgical treatment.
While immediate surgical intervention may be deferred, in these patients, the neurosurgeon or orthopedic surgeon with experience in back surgery can monitor the patient's pain and neurologic deficits over time to inform the decision and timing of elective interventional treatment or surgery. (See "Subacute and chronic low back pain: Surgical treatment", section on 'Indications for spinal surgery'.)
For select patients with chronic radiculopathy, epidural glucocorticoid injections and other nonsurgical interventional therapies may be considered. Such patients include those who have not responded to conservative therapies, those who are not interested in surgery, and those who are not considered appropriate candidates for surgery. Nonsurgical interventional therapies are performed by various specialists, including pain medicine, physical medicine and rehabilitation, orthopedic surgery, and neurosurgery. Details on nonsurgical interventional treatment are discussed separately. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
Patients with severe, chronic, nonspecific low back pain — For selected patients with chronic, refractory low back pain, radiofrequency ablation has shown some evidence of benefit and improvement in disability [70,71]. Epidural and facet joint corticosteroid injections may be considered; however, in patients without radiculopathy, studies have not shown evidence of benefit [72]. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
There is ongoing debate about the role for surgery in the treatment of chronic, nonspecific low back pain without radiculopathy. While some surgeons offer surgery as an elective option for patients with persistent, disabling symptoms of low back pain and significantly impaired quality of life who have not responded to adequate trials of nonsurgical approaches, there is little trial evidence of benefit in these cases. Surgical treatment of nonspecific low back pain, including spinal fusion and lumbar disc replacement, are discussed separately. (See "Subacute and chronic low back pain: Surgical treatment", section on 'Nonspecific low back pain with degenerative disc changes'.)
MANAGEMENT OF ACUTE FLARES —
For patients with chronic low back pain, the recurrence rate of symptoms is estimated to range from 33 to 56 percent when stratified by standardized risk assessment tools [73,74]. In such patients, worsening of symptoms may represent an acute flare of existing symptoms or a new cause of low back pain. These patients should be evaluated to determine if symptoms are suggestive of a new etiology. The evaluation of back pain, including consideration of specific etiologies, is discussed in detail separately. (See "Evaluation of low back pain in adults", section on 'Etiologies' and "Evaluation of low back pain in adults", section on 'Initial evaluation'.)
Once new causes of low back pain have been ruled out, revisiting the approach outlined in this topic during acute flares can help to alleviate symptoms. If specific strategies were effective during prior episodes of back pain, it is worthwhile to prioritize these modalities for each individual patient:
●Reinforce self-care advice and exercise. (See 'Self-care advice' above and 'Exercise therapy' above.)
For patients with a history of recurrent low back pain, participation in a regular exercise therapy program may help prevent future exacerbations of low back pain [75]. (See "Exercise therapy for low back pain", section on 'Exercise and the prevention of low back pain'.)
●Use short-term pharmacologic therapy as needed. (See 'Nonopioid analgesics' above.)
●Refer (or "re-refer") to psychologic or mind-body therapy (cognitive-behavioral therapy or mindfulness-based stress reduction). (See 'Psychologic and mind-body therapies' above.)
●Refer (or "re-refer") for short-term use of passive therapies, including acupuncture, spinal manipulation, and/or massage treatment if needed. (See 'Passive therapies for short-term symptom relief' above.)
THERAPIES THAT WE DO NOT ROUTINELY RECOMMEND —
There are several other interventions that have been used in the treatment of subacute and chronic low back pain, including a variety of pharmacologic interventions and educational approaches as well as different physical treatment modalities. We do not typically use or refer for these treatments in our practice because of limited evidence and alternative treatment options with better efficacy and tolerability.
Pharmacologic therapies — Trials of the following agents have not shown evidence of benefit or have had mixed results in treating low back pain and improving function and, therefore, are not recommended:
●Other antidepressants – Other than duloxetine and tricyclic antidepressants, trials of other antidepressants (eg, non-serotonin-norepinephrine reuptake inhibitors) have not shown evidence of benefit [76-78].
●Benzodiazepines – While benzodiazepines have been used as skeletal muscle relaxants, they are not approved by the US Food and Drug Administration for this indication. If needed, the nonbenzodiazepine skeletal muscle relaxants are preferred to treat symptomatic muscle spasm. (See 'Management of persistent or severe symptoms' above and 'Management of acute flares' above.)
Due to the potential for dependency and abuse, benzodiazepines should not be used for the long-term treatment of chronic low back pain. Furthermore, the combination of benzodiazepines and opioids should be avoided, as this combination is associated with a marked increase in risk of overdose compared with an opioid alone [79,80]. (See "Benzodiazepine use disorder" and "Benzodiazepine poisoning" and "Acute opioid intoxication in adults".)
●Antiepileptics – Antiepileptics (ie, gabapentinoids and topiramate) are widely used in the treatment of various pain syndromes, including neuropathic pain, but evidence supporting their efficacy in the treatment of patients with subacute or chronic low back pain (with or without sciatica) is limited, with mixed results [81-87]. In addition, there are frequent negative side effects reported with these medications, limiting overall patient tolerability.
●Systemic corticosteroids – No trial has evaluated systemic corticosteroids for the treatment of subacute or chronic, nonradicular low back pain [88]. In studies of acute low back pain, corticosteroids were associated with improved short-term pain and function in patients with radicular pain; in patients with nonradicular, acute low back pain, corticosteroids were associated with slightly worsened pain but slightly improved function. (See "Treatment of acute low back pain", section on 'Other medications' and "Acute lumbosacral radiculopathy: Treatment and prognosis", section on 'Systemic glucocorticoids'.)
●Glucosamine – There are few data to support the use of glucosamine for low back pain. In a six-month, randomized trial of patients with chronic low back pain and degenerative lumbar osteoarthritis, there were no differences in pain or quality-of-life scores between the glucosamine sulfate and placebo groups [89]. The use of glucosamine for the treatment of knee osteoarthritis is discussed elsewhere. (See "Management of knee osteoarthritis", section on 'Nutritional supplements'.)
●Herbal preparations – While a 2014 systematic review of randomized trials showed some evidence for efficacy for topical Capsicum frutescens (cayenne), oral Harpagophytum procumbens (Devil's claw), oral Salix alba (white willow bark), topical Symphytum officinale (comfrey root extract), and topical lavender essential oil in treating low back pain, these were short-term trials with methodologic limitations [90]. Most notably, the herbal treatments were not compared with nonsteroidal anti-inflammatory drugs or acetaminophen.
Herbal medications may contain impurities and can potentially interact with other drugs, and some may have significant adverse effects. Use and effects of herbal medicines are discussed in more detail separately. (See "Overview of herbal medicine and dietary supplements", section on 'Purity and adulteration' and "Overview of herbal medicine and dietary supplements", section on 'Safety'.)
●Cannabis and cannabinoids – High-quality data on the efficacy of cannabis and cannabinoids specifically for the treatment of low back pain are lacking [91]. The use of these agents in the management in chronic non-cancer pain is discussed elsewhere. (See "Overview of pharmacologic management of chronic pain in adults".)
Nonpharmacologic therapies
●Intensive education – Intensive education may be beneficial in subacute low back pain. However, data are lacking to support the efficacy of intensive education as a sole intervention in the management of chronic low back pain, rather than as an adjunct to other approaches, such as exercise. In a systematic review of educational interventions, patients with subacute low back pain who received an intensive, in-person education session lasting at least two hours had better outcomes, with improved pain and function and a quicker return to work than those receiving the usual care [92]. However, those with chronic back pain benefited less from this intervention.
Pain neurophysiology education is a particular type of pain education that focuses upon the neurophysiology and psychosocial contributors of pain, rather than on the biomechanical aspects of pain. In a meta-analysis including seven randomized controlled trials and 313 patients with chronic low back pain, patients had moderate improvement in pain immediately following the intervention, with smaller improvements in pain and disability at three months [93]. In another small trial of patients with chronic low back pain, the combination of pain neurophysiology education and exercise improved short-term pain intensity and function compared with exercise therapy alone [94].
●Back school – Back school is an intervention originally developed in Sweden consisting of education and a skill program, including exercise therapy. Generally, lessons are provided to groups of patients and supervised by a physical therapist or other therapist trained in back rehabilitation; although, the content of back school interventions vary, and back school based on the traditional Swedish approach is not widely available in the United States. There is overlap between back school and group exercise, educational interventions, and multidisciplinary rehabilitation. Back school may be a reasonable therapeutic option for patients with subacute or chronic low back pain who are interested in it, but there is limited evidence supporting its effectiveness.
There is low-quality evidence that back school was modestly more effective than no treatment for short-term pain control, but these effects were not seen in intermediate- or long-term follow-up [95]. In addition, back school was no more effective for pain control than medical care, passive physiotherapy, or exercise in intermediate- or long-term follow-up.
●Use of lumbar supports – The benefit of lumbar supports for patients with chronic low back pain is uncertain [96]. In an open-label, randomized trial, use of an elastic belt in patients with subacute low back pain modestly reduced the need for pain medication and improved functional status at 30 and 90 days [97]. However, longer-term outcomes are unknown, and some have raised concerns that use of a lumbar support device might lead to activity restriction by reinforcing awareness of a "back problem," thereby discouraging exercise participation. Thus, while lumbar supports are not routinely recommended, they may provide some benefit for patients with subacute low back pain who are actively engaged in recommended therapies and who will remain active.
●Firm mattress/sleeping surface – High-quality data to determine an optimal sleeping surface firmness for patients with subacute and chronic low back pain are lacking. Two small trials in patients with low back pain suggested that softer or back-conforming mattresses led to improved outcomes (decreased pain and improved function) compared with firmer mattresses [98,99].
Other physical modalities — Many physical modalities are offered in the treatment of patients with chronic low back pain. For the modalities listed below, there is little evidence of consistent benefit from randomized, controlled studies, although patient expectations of benefit and placebo effects may play a role in their therapeutic value [100,101].
●Interferential therapy [102-104]
●Low-level laser therapy [105-111]
●Ultrasound [16,46,112-114]
●Shortwave diathermy [115,116]
●Traction [117]
●Transcutaneous electrical nerve stimulation [118]
●Percutaneous electrical nerve stimulation [119-122]
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Low back pain in adults (The Basics)")
●Beyond the Basics topic (see "Patient education: Low back pain in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Initial management – Patients with back pain should undergo an evaluation before making a presumptive diagnosis of "nonspecific low back pain." (See "Evaluation of low back pain in adults".)
•Patient risk assessment – Patients with pre-existing psychologic conditions, job dissatisfaction, obesity, smoking, and other factors are at higher risk for developing chronic symptoms and may benefit from more intensive interventions. (See 'Risk assessment for chronic, disabling pain' above.)
•Self-care advice – All patients with low back pain should be advised to maintain activity as tolerated. Heating pads may be used for short-term symptomatic relief. We also provide patient education on stretching and graded activity. (See 'Self-care advice' above.)
●Initial treatment options – The following treatments may be used as monotherapy or in combination, depending on patient interest and motivation:
•Nonopioid analgesics – In patients with subacute and chronic low back pain, we suggest nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief and to facilitate participation in exercise and other adjunctive therapies (Grade 2C). Options and doses are provided in the table (table 3). Acetaminophen is an alternative for those who cannot take NSAIDs. (See 'Nonopioid analgesics' above.)
•Exercise – In patients with subacute or chronic low back pain, we suggest participation in a regular exercise program (Grade 2C). Exercise therapy improves function and alleviates pain symptoms. Most exercise therapies appear to be similarly effective, and choice is guided by availability and patient interest. Patients with or at risk for chronic, disabling pain may benefit from more intensive, supervised exercise programs. (See 'Exercise therapy' above.)
•Psychologic and mind-body therapies – We suggest cognitive-behavioral therapy (CBT) for patients with higher-risk, subacute low back pain and chronic low back pain causing significant functional impairment (Grade 2C). CBT can improve pain and reduce disability. (See 'Psychologic and mind-body therapies' above.)
Mindfulness-based stress reduction, biofeedback, and progressive relaxation are additional options for addressing psychosocial contributors to pain.
•Passive therapies – Short-term interventions such as spinal manipulation, acupuncture, or massage may be considered for selected patients. These treatments may provide short-term symptomatic improvement and potentially facilitate subsequent participation in active therapies. (See 'Passive therapies for short-term symptom relief' above.)
●Persistent or more severe symptoms – If initial therapy is inadequate, we offer additional therapies.
•Pharmacologic options – For subsequent pharmacologic therapy, we suggest the addition of a nonbenzodiazepine skeletal muscle relaxant (eg, tizanidine or cyclobenzaprine) for up to four weeks (Grade 2C). (See 'Skeletal muscle relaxants for short-term relief' above.)
If longer-term options beyond four weeks are needed, we suggest duloxetine (Grade 2C). Tricyclic antidepressants are reasonable alternatives. (See 'Longer-term pharmacologic options' above.)
•Multidisciplinary rehabilitation – Multidisciplinary rehabilitation combines graded exercise therapy with a psychologic intervention component. These intensive programs require substantial commitment from the patient and are not widely available.
●Management of refractory, disabling symptoms – For patients with severe symptoms persisting beyond 12 weeks, the focus of care shifts toward reducing symptoms, maximizing coping, and preventing disability, rather than symptom resolution.
•Medications – Skeletal muscle relaxants may be used over the long term to provide relief of symptoms. (See 'Long-term use of skeletal muscle relaxants' above.)
Combination therapy may be considered, including combinations of NSAIDs with skeletal muscle relaxants or duloxetine, or duloxetine combined with skeletal muscle relaxants. Patients should be monitored closely for adverse effects on combination regimens. (See 'Combination therapy' above.)
Opioids should not be used routinely for the management of chronic low back pain, given limited efficacy and potential for harm. Opioids should be restricted to patients who are not at risk for drug dependence or misuse. The lowest possible dose should be used, and use should be monitored closely. (See 'Restricted use of opioids' above.)
•Indications for imaging – Patients who have not improved after four to six weeks of conservative therapy and who did not receive imaging on initial evaluation should be re-evaluated. Details regarding imaging study selection are discussed separately. (See "Evaluation of low back pain in adults", section on 'Determining if imaging is indicated'.)
•Indications for specialty care – Patients with chronic, persistent symptoms lasting greater than 12 weeks, despite medical and nonpharmacologic treatment, may be candidates for surgical or nonsurgical interventional treatment. (See 'Indications for specialty care' above.)
