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Chronic Low Back Pain in Adults: Evaluation and Management

This is a corrected version of the article that appeared in print.

Donald Clinton Maharty, DO
Shaun C. Hines, DO
Regina Bray Brown, MD

American Family Physician. 2024;109(3):233-244.

Author disclosure: No relevant financial relationships.

Chronic low back pain, defined as lumbar pain persisting for 12 weeks or more, occurs in about 13% of U.S. adults. Patients with chronic low back pain should have a history and physical examination to identify red flags that may indicate serious conditions that warrant immediate intervention or yellow flags (i.e., psychological, environmental, and social factors) that indicate risk of disability. The examination should include an evaluation for radicular symptoms. Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy. Patients should avoid bed rest. Nonpharmacologic treatment is first-line management and may include therapies with varying evidence of support, such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy. Pharmacologic interventions are second-line treatment. Nonsteroidal anti-inflammatory drugs are the initial medication of choice; duloxetine may also be beneficial. Evidence is inconclusive to recommend the use of benzodiazepines, muscle relaxants, antidepressants, corticosteroids, insomnia agents, anticonvulsants, cannabis, acetaminophen, or long-term opioids. Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain. Most patients with chronic low back pain will not require surgery; evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk. Physicians should consider prevention of chronic low back pain when patients present with acute back pain. Screening tools are available to predict the progression from acute to chronic low back pain, and targeted treatment strategies are beneficial for preventing progression.

Low back pain is a common reason for adults to visit their physician. Based on a systematic review of 165 studies from 54 countries, the lifetime prevalence of low back pain is approximately 40%.1 Globally, low back pain is the most prevalent and disabling condition that benefits from rehabilitation and is the highest generator of health care expenditure and disability.2–4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Routine imaging is not recommended without clinical indications. Imaging should be performed when red flags are present, there is a neuromuscular deficit, or chronic low back pain, with or without nerve-root involvement, does not resolve with conservative therapy.33,36 C Clinical guidelines and expert opinion
In the absence of conditions that require specific medical or surgical attention, non-pharmacologic treatments are the first-line choice for management of chronic low back pain, including modalities that are based on varying levels of evidence, such as behavioral counseling, exercise and physical therapy, spinal manipulation, massage, heat, dry needling, acupuncture, and transcutaneous electrical nerve stimulation.22,36 C Clinical guidelines and expert opinion
Studies on the treatment of back pain support the benefit of early patient education that focuses on two issues: (1) the importance of remaining physically active and avoiding bed rest; and (2) setting expectations for a positive treatment response because this may help improve outcomes.36,46 C Multiple practice guidelines
Spinal manipulation results in small improvements in pain and function in patients with chronic low back pain, with outcomes that are comparable with, but not superior to, other recommended therapies.22,58–60 B Cochrane review and other systematic reviews and meta-analyses
NSAIDs are considered the best initial pharmacologic treatment for chronic low back pain. There is evidence that NSAIDs are more effective than placebo with respect to pain and disability.22,36,46,67–69 B Cochrane reviews and clinical guidelines
Studies demonstrate that muscle relaxants have no benefit for chronic low back pain compared with controls; studies also show that benzodiazepines have no benefit compared with placebo and there is significant risk of harm.24,25,69 B Cochrane and other systematic reviews and meta-analyses
Epidural corticosteroid injections are not effective for providing long-term relief of disability or pain. Based on limited data, they may provide a slight reduction in short-term pain and disability for patients with radicular pain.76 B Cochrane review

NSAIDs = nonsteroidal anti-inflammatory drugs.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

DONALD CLINTON MAHARTY, DO, FACOFP, FAAFP, MAML, DABOM, is vice president of medical education at Cape Fear Valley Health, Fayetteville, N.C., and regional associate dean at Campbell University Jerry M. Wallace School of Osteopathic Medicine, Buies Creek, N.C.

SHAUN C. HINES, DO, DABOM, is the medical director of the Bladen Health Department, Bladenboro, N.C., and adjunct faculty at Campbell University Jerry M. Wallace School of Osteopathic Medicine, Bladenboro.

REGINA BRAY BROWN, MD, FAAFP, MHPE, is a program director for the Campbell University/Harnett Health Family Medicine Residency Program, Lillington, N.C., and director of medical education for Harnett Health, Lillington.

Address correspondence to Donald C. Maharty, DO, Cape Fear Valley Health, Department of Graduate Medical Education, 1638 Owen Dr., Fayetteville, NC 28304 (dmaha@capefearvalley.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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