Treatment for Chronic Low Back Pain

Evidence strongly suggests that only intensive treatment using a combination of physical and psychological rehabilitation programs can reduce pain and improve function in patients with chronic low back pain. Even with the best treatments, many patients with chronic back pain fail to experience complete pain relief. They often must develop methods for improving daily life in the face of some persistent pain.

Noninvasive Therapies. In general, early treatments for severe low back pain or chronic low back pain are similar to those of acute uncomplicated low back pain. The following are the most common noninvasive treatments for chronic back pain of unknown causes:

• Pain Relievers. Pain relievers, particularly non-steroidal anti-inflammatory drugs (NSAIDs), may help relieve symptoms, although they can have severe effects on the gastrointestinal tract over time. Some doctors have recommended long-term opioids for patients with severe chronic pain, but studies suggest they do not improve activity levels and can have significant side effects.
• Corticosteroid injections may be helpful for some patients.
• Exercise and Physical Therapy. Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although patients often find it difficult to sustain.
• Antidepressants. Tricyclic antidepressants may be helpful for some patients.
• Cognitive-Behavioral Therapy. This form of psychological therapy helps change behavior and attitudes toward pain.
• Alternative Therapies. Transcutaneous electrical nerve stimulation (TENS) and massage may relieve pain in certain cases. Other mind-body techniques such as relaxation and meditation may be helpful by reducing stress. Other promising approaches, such as Botox injections and lidocaine patches, are also being investigated.
• Acupuncture. A study in the British Medical Journal found that acupuncture provided longer lasting relief than physical therapy. For the study, 129 people were given either six acupuncture or physical therapy sessions. The study authors cautioned that the benefit of acupuncture greatly depended on the health care provider’s experience. Another study, published in the Archives of Internal Medicine, reported that acupuncture worked better than no treatment at all.
• Yoga. Yoga relieves low back pain better than conventional exercise or self-help books, according to a study published in the December 20, 2005 issue of Annals of Internal Medicine. For the study, 101 adults with low back pain who were randomly assigned to one of three groups. One group attended yoga classes and lessons; the second did aerobics, weight training, and stretching; and third group read a self-help book about back pain. After 12 weeks, those who took yoga could better perform daily activities requiring the back than those in the other two groups. After 26 weeks, those who took yoga had less pain and better back function, and used less pain relievers than the others.

Surgery and Invasive Procedures. Patients should always try all possible non-surgical treatments before opting for surgery. The most common reasons for surgery for low back pain are sciatica and spinal stenosis. Some experts believe that less than 1% of back pain patients need aggressive medical or surgical treatments.

Nevertheless, when it is appropriate, surgery can provide great relief. Many approaches and procedures are available or being investigated. However, there have been few well-conducted studies to determine if any type of back pain surgery works better than others, or if a single procedure is better than no surgery at all.

People who are obese and have low back pain may benefit from surgical weight loss surgery. A study in the journal Obesity Surgery found that bariatric (stomach stapling) surgery significantly improves the degree of disability in morbidly obese patients who have low back pain.

Before any surgery, it is extremely important that the patient is sure that the surgeon has had significant experience with the procedure.

Specific Approaches for Patients with Herniated Disks

Nonsurgical Procedures. Patients with herniated disks should try nonsurgical treatments for at least 1 month before considering surgery. Nonsurgical procedures include spinal manipulation, massage therapy, and physical therapy. Patients should wait at least 2 to 3 weeks before using spinal manipulation.

Surgery. According to a 2001 review of studies, about 10% of patients have such bad back pain after 6 weeks that a diskectomy may be considered. Diskectomy is the standard procedure for herniated disks. For many of these patients, surgery may bring significant relief. In one study, 70% of patients with moderate to severe sciatica who had had surgery reported improvement. In most patients, the improvement was better than that achieved by 4 years of nonsurgical treatments. It is not clear if surgery maintains its advantage for longer periods of time.

Specific Approaches for Patients with Spinal Stenosis

Preventing Falls. Falling is a risk for patients with spinal stenosis. They should avoid alcohol and sedatives. Leg strengthening exercises such as walking and cycling may be helpful.

Nonsurgical Treatments. The use of common pain relievers such as NSAIDs, physical therapy, and spinal injections may be helpful for some patients.

Surgery. If pain is persistent, patients may require surgery, most often a procedure called decompressive laminectomy. Some patients may require spinal fusion as well. Studies suggest that surgery reduces back pain in many patients with spinal stenosis, at least for a few years. However, by 4 years after surgery, 30% of patients have severe pain again, and 10% have another operation. It should be noted that surgery does not always improve outcome and, in some cases, can even make it worse. Surgery can be an extremely effective approach, however, for certain patients whose severe back pain does not respond to conservative measures.

Specific Approaches for Patients with Piriformis Syndrome

Nonsurgical Treatments. The general approach for patients with piriformis syndrome is corticosteroid injections and physical therapy. Botox injections are showing promise.

Surgery. In carefully selected patients who do not respond to physical therapy and injections, some studies report dramatic pain relief with a surgical procedure that releases the piriformis muscle.

Specific Approaches for Patients with Degenerative Disk Disease

A new type of physical therapy called Souchard's global postural re-education helps relieve back pain symptoms due to degenerative disk disease, according to research presented at the 2005 American Academy of Neurology Annual Meeting. The method involves stretching weakened muscles around the spine and stomach. Researchers studied 102 people who had at least 7 months of severe back pain due to disk disease and who had received different types of treatment for more than 6 months. They attended the new physical therapy sessions two times the first week, then once a week for an average of 5 months. Ninety-two percent had significant pain relief and returned to their normal daily activities. The majority of those who had pain relief felt better after 3 weeks, and remained pain free for almost 2 years.

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Review Date: 4/26/2006
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital