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BMJ. 2007 October 13; 335(7623): 744.
PMCID: PMC2018765
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People with low back pain have a good choice of treatments

Cognitive behaviour therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are the best non-drug treatments for low back pain lasting more than four weeks, according to a systematic review. All of them worked better than placebo or sham treatment in randomised trials—they reduced pain and improved function by 10-20%. Acupuncture and a style of yoga called viniyoga may also be helpful, but the evidence isn't particularly good. Evidence on back schools, interferential therapy, laser treatment, lumbar supports, transcutaneous electrical nerve stimulation, traction, and ultrasonography is even worse, and guidelines based on the review don't recommend them.

Patients with acute pain (lasting less than four weeks) may get some relief from warming the lower back with a heated pad or blanket, says the review. Spinal manipulation is the next best option, although again the benefits are modest.

Another systematic review by the same authors identified paracetamol and non-steroidal anti-inflammatory drugs as moderately effective treatments for acute and chronic low back pain. The linked guidelines say they are a reasonable first line choice. Most patients can expect a 10-20% improvement in pain. Opioids or tramadol can be useful for people who need stronger pain relief, but there is always a risk of dependence. So use a short course and reassess.

The review reported that muscle relaxants such as tizanidine help relieve acute pain, and tricyclic antidepressants have small to moderate effects on chronic pain. But systemic steroids do not work for anyone.


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