Which therapies are most effective for chronic low back pain?

Short answer
- First-line: nonpharmacologic, active therapies — exercise therapy (supervised, graded, and/or individually tailored programs), physical therapy, and psychologically informed approaches (CBT, pain self-management). These have the best evidence for improving pain and function in chronic low back pain (CLBP).
- Second-line/add-on: short courses of NSAIDs (oral/topical) for symptom relief; duloxetine for some patients with chronic pain; targeted therapies (acupuncture, spinal manipulation, yoga, Tai Chi) can help some people.
- Use injections or surgery only for specific indications (radicular pain with nerve compression, progressive neurologic deficit, structural instability) after conservative therapy has failed.

What “most effective” means
- For CLBP (usually defined as >12 weeks), most treatments improve pain and function modestly. The strongest, most consistent benefits come from active rehabilitation and multidisciplinary/psychological approaches that address physical and psychosocial contributors.

Evidence-based therapies (practical summary)
1. Exercise and active rehabilitation (best-supported)
- Types: supervised exercise, graded activity, individualized strengthening/core-stability, aerobic exercise, yoga, Tai Chi.
- Benefits: small-to-moderate improvements in pain and function; better long-term outcomes than passive care or bed rest.
- Recommendation: start early, encourage regular home programs, consider supervised PT for technique and progression.

2. Cognitive-behavioral and psychologically informed interventions
- Includes CBT, acceptance and commitment therapy (ACT), pain education, and multidisciplinary pain programs.
- Benefits: improved coping, function, reduced disability and often reduced pain.
- Especially useful when fear-avoidance, catastrophizing, depression, or sleep problems are present.

3. Multidisciplinary rehabilitation
- Combines exercise, education, behavioral therapy, and medical management.
- Best for people with persistent pain and disability; shown to improve function and return-to-work.

4. Manual therapies, spinal manipulation
- Can provide short-term pain relief; best used as part of a broader program with exercise.
- Evidence is mixed for long-term benefit.

5. Acupuncture
- Modest benefit for some patients; can be considered when patients prefer it or do not respond to first-line measures.

6. Pharmacologic therapies (adjuncts, short-term)
- NSAIDs (oral or topical): first-line medication for short-term symptomatic relief.
- Acetaminophen: limited benefit for CLBP; less preferred than NSAIDs.
- Duloxetine: evidence for moderate benefit in chronic musculoskeletal pain for selected patients.
- Muscle relaxants: may help short-term for acute exacerbations; limited use in chronic care.
- Anticonvulsants (gabapentin/pregabalin): not recommended for nonspecific CLBP; may help neuropathic radicular pain.
- Opioids: not recommended for routine long-term management because risks generally outweigh benefits; may be considered only after careful multidisciplinary assessment and monitoring for selected patients.

7. Injections and procedures
- Epidural steroid injections: may reduce radicular leg pain from nerve-root inflammation/stenosis temporarily; limited effect for nonspecific axial CLBP.
- Facet joint injections/medial branch blocks: selective diagnostic/therapeutic role in carefully selected patients.
- Radiofrequency ablation: may help for confirmed facet-mediated pain.

8. Surgery
- Indicated for specific structural problems (progressive neurologic deficit, severe spinal stenosis with neurogenic claudication, instability, selected disc herniation) or when severe, persistent symptoms do not respond to conservative care and imaging matches clinical findings.
- Outcomes depend on proper patient selection; surgery is not routinely helpful for nonspecific CLBP.

What to avoid routinely
- Prolonged bed rest.
- Routine imaging in the absence of red flags (does not improve outcomes and can increase unnecessary interventions).
- Routine long-term opioid therapy.
- Unselected use of surgery for nonspecific low back pain.

Red flags (seek urgent care)
- Severe or progressive neurologic deficit (weakness, numbness).
- New bowel or bladder dysfunction or saddle anesthesia (possible cauda equina).
- Fever, unexplained weight loss, history of cancer, recent significant trauma, intravenous drug use — suggest possible infection, malignancy, fracture.

Practical approach (stepwise)
1. Assess for red flags and radicular/neurologic signs.
2. Reassure, educate about prognosis, encourage activity and return to normal activity/work as tolerated.
3. Start structured exercise program and/or physical therapy; consider CBT or pain self-management.
4. Use short-term NSAIDs or topical analgesics for symptom control; consider duloxetine if indicated.
5. If radicular pain or structural lesion suspected, consider targeted diagnostics and referral to spine specialist for injections or possible surgery.
6. Consider multidisciplinary pain program for refractory cases with significant disability.

If you want, I can:
- Suggest an exercise starter plan (general, home-based) or
- Outline specific questions to ask a clinician or physical therapist,
- Or tailor recommendations based on your age, imaging findings, pain pattern, medical history, or whether you have radicular symptoms.