Traditional treatments such as opioid pain pills, steroid injections and surgery are not necessarily very effective and can have significant downsides.
But good evidence supports certain nondrug and nonsurgical options. That’s why 2017 guidelines from the American College of Physicians recommend them — and suggest drugs or surgery only when other therapies fail.
That advice is backed up by a nationally representative Consumer Reports survey of 3,562 back-pain sufferers. More than 80 percent who tried yoga or tai chi, massage therapy or chiropractic said it had helped them, as did more than 60 percent of respondents who tried acupuncture or physical therapy.
But experts agree that a personalized plan is best. “What works for one person may fall flat in another,” says Jack Ende, past president of the ACP.
So which steps should you take when your back starts aching, and in what order? Here’s what the research and the experts recommend.
1: When back pain first strikes
Back pain is considered acute when a new episode lasts for less than four weeks. If your back begins to hurt, experts suggest starting with the following:
●Heat or ice. For instance, a warm shower, hot-water bottle or heating pad can reduce pain. Ice may also feel good.
●Gentle activity. It’s best to resume normal activity. (If you can’t, walk for a few minutes every few hours, Ende says.) If you’re able, try easy stretches.
●Over-the-counter pain relievers if needed. While the ACP emphasizes nondrug measures, Ende says ibuprofen (Advil or generic) or naproxen (Aleve or generic) can be used for a week or two.
2: If you're still in pain after a week or two . . .
If you still have a lot of pain, your doctor may provide a home-based exercise program or refer you to physical therapy for supervised exercise. PT may include massage or low-level laser therapy, but the exercise component is key.
After a month or two, you may feel well enough to get back to — or start — a normal exercise program. That’s important: People who have had lower back pain but are active are about one-third less likely to see it recur, according to a 2017 review published in the American Journal of Epidemiology.
3: When pain persists for months
For pain that continues even after a couple of months of exercise or PT, the ACP recommends considering these:
Yoga and tai chi. They strengthen core muscles, relieving pressure on your back, says Benjamin Kligler, national director of the Integrative Health Coordinating Center for the Veterans Health Administration.
Your doctor may be able to refer you to a local class for yoga (opt for a gentle form) or tai chi. Or find a list of certified instructors through the American Tai Chi and Qigong Association, the Yoga Alliance or the International Association of Yoga Therapists.
Cognitive behavioral therapy or mindfulness-based stress reduction. If back pain has you feeling depressed or anxious, CBT — which focuses on circumventing negative thought patterns — may help. MBSR increases awareness and acceptance of pain with practices such as yoga and meditation.
Adults with chronic back pain who did either technique for two hours a week for eight weeks reported significant relief, according to a 2016 JAMA study. Ask your doctor for a referral, or check the website of the Association for Behavioral and Cognitive Therapies.
Spinal manipulation. Used by chiropractors, osteopaths, physical therapists and some massage therapists, it involves moving the joints of the spine. A review published last year in JAMA found that spinal manipulation significantly improved pain and function for those with acute lower back pain.
Check your health insurer’s website for licensed chiropractors and doctors of osteopathic medicine.
Acupuncture. This involves inserting very fine needles into specific points on the body. A large review of studies found that acupuncture outperformed sham treatment and no treatment for all kinds of chronic pain, including back pain. But it may cost you $100 or more per session. Make sure any acupuncturist you see is licensed by the state. Find listings on the National Certification Commission for Acupuncture and Oriental Medicine’s website.
What about meds and surgery?
If none of the above help or you’re in significant pain while starting a treatment such as PT, a week or two of medication is reasonable, says Chou. The ACP recommends over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen. If you can’t take an NSAID or need stronger relief, consider the prescription pain pill tramadol (Ultram and generic) or the antidepressant duloxetine (Cymbalta and generic).
The nerve-pain drug gabapentin (Neurontin, Gralise, Horizant and generic) is often prescribed for muscle pain, but research suggests that it’s not very effective and causes side effects. And groups such as the ACP and the American Academy of Family Physicians strongly advise against the use of opioid painkillers such as oxycodone (OxyContin and generic).
Should surgery ever be an option? Only for persistent pain, numbness and tingling that radiates down a leg from a herniated disk; severe or progressive weakness in a foot or leg; or spinal stenosis that hasn’t responded to therapies such as PT, Ende says.
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