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Short Summary
Main recommendation: For chronic back pain (lasting three to six months or more), treatment should focus on screening for anxiety and depression, using psychological therapies, and offering evidence-supported non-drug options, with realistic goals for living actively rather than expecting a complete cure. The video also covers when imaging and specialist referral are appropriate, and which treatments to avoid.
Key Points
- Chronic back pain is defined here as pain present for at least three to six months, even if it is the patient's first episode.
- By the three-month mark, patients with non-resolving pain should already have had physical therapy and imaging (plain AP and lateral spine films for non-specific pain, or MRI if a neurologic cause such as herniated disc or spinal stenosis is suspected).
- Many patients with ongoing chronic pain have anxiety or depression contributing to their symptoms, so screening and offering antidepressants or counseling is described as one of the most useful options.
- Evidence supports cognitive behavioral therapy and biofeedback as helpful parts of a comprehensive plan.
- Patients who expect benefit before starting tend to benefit most, so getting the patient on board with the plan matters.
- There is no good evidence that laser therapy, lumbar supports, or traction help chronic back pain, and these should not be recommended.
Details Worth Noting
- Concrete instructions: At the three-month point, confirm physical therapy and appropriate imaging have been completed. Screen for anxiety and depression. Discuss long-term acetaminophen and NSAID costs and benefits; if using NSAIDs long term, add a proton pump inhibitor to reduce the risk of gastric ulcers. Discuss options such as acupuncture, exercise therapy (core strengthening or flexion-extension stretching, self-performed or guided by a physical therapist), trained massage therapy, yoga, and chiropractic manipulation. Be aware that opioids and muscle relaxants carry significant addiction risk in chronic pain.
- Heel tap test: Tell the patient the test may cause pain, then gently tap the heel. The video says no one should have pain from this regardless of back pathology; if discomfort is reported, the video suggests considering somatization disorder or a non-organic cause.
- Consider alternative pain sources radiating to the back, such as kidney or sacroiliac joint problems; elderly patients may need additional workup to rule these out.
- Patients with a spondyloarthropathy-type picture (pain worse at night and on arising, improving with movement) can be referred to Rheumatology if initial imaging is negative.
- Patients are rarely completely cured, so goals should be set realistically around managing pain and staying active and productive.
- UCLA's Pain Management Center and the physiatry service at the UCLA Spine Center can offer comprehensive care, including non-surgical procedures and clinical trials.
Bottom Line
Chronic back pain is usually managed rather than cured, so success depends on addressing psychological factors, choosing evidence-supported therapies, avoiding ineffective and high-risk treatments, and setting goals the patient can realistically achieve.
