Changes in pharmacological management of low back pain: Real-world evidence from a 4-year comparison (2021-2025).

OBJECTIVE: Contemporary guidelines recommend conservative, non-pharmacological management as first-line treatment for low back pain (LBP), yet real-world implementation remains variable. Understanding temporal trends in prescribing patterns is essential for evaluating alignment with evidence-based recommendations. The purpose of this study was to evaluate changes in pharmacological and non-pharmacological treatment strategies for LBP in a tertiary physical medicine and rehabilitation (PMR) outpatient clinic by comparing 2 time periods 4 years apart. METHODS: This retrospective observational study reviewed medical records of consecutive adult patients (≥18 years) presenting with LBP during October-November 2021 (n=252) and October-November 2025 (n=267) at a tertiary PMR center. Treatment strategies were categorized as non-steroidal anti-inflammatory drugs (NSAIDs) alone, muscle relaxants alone, combination therapy (NSAID+muscle relaxant), or non-pharmacological management only. Statistical comparisons were performed using Chi-square tests and odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Overall pharmacological prescribing decreased significantly from 51.6% (130/252) in 2021 to 36.3% (97/267) in 2025 (OR: 0.54, 95% CI: 0.38-0.77, p=0.001). NSAID prescribing declined from 25.4% to 13.5% (p=0.001), whereas non-pharmacological management increased from 48.4% to 63.7% (p=0.001). The shift toward conservative management was most pronounced in patients aged ≥65 years, with pharmacological prescribing decreasing from 58.3% to 36.5% (OR: 0.41, 95% CI: 0.22-0.77, p=0.005). CONCLUSION: Treatment strategies for LBP in a tertiary PMR setting appeared to reflect greater alignment with contemporary guideline recommendations over the 4-year study period. These findings may reflect increasing alignment with contemporary evidence-based recommendations emphasizing non-pharmacological approaches and reduced pharmacological exposure, particularly in older adults at higher risk of medication-related adverse events.