On this page, we answer some questions you may have if you’re affected by pain and discomfort in your lower back which has no identifiable cause (it’s ‘non-specific’) and has lasted longer than 3 months (it’s ‘chronic’). On this page, we look at the potential benefits and harms of various non-invasive, non-surgical treatment options. The answers are based on the latest trustworthy evidence from Cochrane and NHS advice.
You can scroll through this page or click on the links below to jump to a particular section:
- What is non-specific low back pain?
- When is low back pain considered ‘chronic’?
- Non-drug treatments for chronic low back pain
- Drug treatments for chronic low back pain
- Other options recommended by the National Institute of Health and Care Excellence (NICE)
- Other options not recommended by NICE
What is non-specific low back pain?
When pain and discomfort in your lower back do not have an identifiable cause (for example, it’s not caused by a fracture, infection, cancer or nerve root pain), it’s called ‘non-specific’. Non‐specific low back pain is the most common type of back pain.
When is low back pain considered ‘chronic’?
Often, back pain will improve on its own within a few weeks. The NHS website has advice on things you can do to help speed up your recovery. Pain is considered:
- ‘acute’ when it lasts for under 6 weeks
- ‘subacute’ when it lasts between 6 weeks and 3 months
- ‘chronic’ when it lasts over 3 months
Non-drug treatments for chronic low back pain
Self-management is a key part of managing low back pain, with a focus on continuing normal activities.
Exercise therapies for chronic low back pain
What are exercise therapies for treating low back pain?
Exercise therapies are designed or prescribed by health professionals and cover a range of exercise types and durations. Examples include general fitness programmes delivered in a group setting, aerobic exercises such as walking programmes, and strengthening of specific muscles or groups of muscles. Exercise therapy aims to reduce pain and disability by increasing muscle and joint strength, and improving muscle function.
Can exercise therapies help with chronic low back pain and might they have any unwanted effects?
The National Institute for Health and Care Excellence (NICE) suggests considering group exercise programmes, and that people’s “specific needs, preferences and capabilities [should be taken] into account when choosing the type of exercise”.
Cochrane evidence on exercise therapies suggests that:
- compared to no treatment, placebo or usual care (which typically includes physiotherapy, exercise, and/or medication), exercise therapy:
- is probably more effective at reducing pain
- is probably also slightly more effective at reducing functional limitations – although this benefit is probably small and unlikely to be important.
- compared to other conservative treatments (such as education), exercise therapy may slightly reduce pain and probably slightly improves functional limitations outcomes. However, these benefits are small and unlikely to be important.
- Studies have not always provided reliable information about the possible unwanted effects of exercise therapies. When studies have provided this information, unwanted effects tend to be minor, most commonly increased lower back pain and muscle soreness.
Can psychological therapies help with chronic low back pain and do they have any unwanted effects?
- NICE recommends that health professionals “consider psychological therapies using a cognitive behavioural approach… but only as part of a treatment package including exercise”.
- Cochrane evidence about psychological therapies is based on people with a variety of types of chronic pain, many (but not all) of whom had lower back pain. The evidence suggests that:
- compared with doing nothing, cognitive-behavioural therapy (CBT) probably slightly reduces pain and disability, and may reduce distress, up to 12 months after treatment.
- There is not enough reliable information about other types of psychological therapies, such as acceptance and commitment therapy (ACT).
- There is not enough information about possible unwanted effects of psychological therapies.
- Read more in this blog: Managing chronic pain in adults: the latest evidence on psychological therapies
Yoga for chronic low back pain
Can yoga help with chronic low back pain and might yoga have any unwanted effects?
- NICE does not mention yoga specifically, but it does suggest that people with chronic low back pain could “consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches)”. Yoga is a form of mind-body fitness.
- Cochrane evidence on yoga suggests that:
- Doing yoga is probably better for improving pain and back-related function after three months, compared with doing no exercise. However, the improvements are small and may not be noticeable.
- There is probably little or no difference between yoga and other types of back‐focused exercises in terms of improving back‐related function, but the evidence is very uncertain about how yoga compares with other types of exercise in terms of improving pain.
- Yoga may carry more risk of unwanted effects compared with doing no exercise, but there may be little to no difference between yoga and other types of exercise in terms of unwanted effects. Yoga may not increase the risk of serious harms.
- Read more in this blog: Is yoga good for back pain? Here’s the evidence
Can acupuncture help with chronic low back pain and does acupuncture have any unwanted effects?
- NICE advises that health professionals “Do not offer acupuncture for managing low back pain”.
- Cochrane evidence on acupuncture suggests that:
- compared with usual care (which typically includes medication, physiotherapy, and/or exercise), acupuncture may have little to no important benefit in terms of reducing pain, improving back function, or improving quality of life in the short term.
- Unwanted effects of acupuncture may be minor-to-moderate. The most commonly reported unwanted effects include pain at the point where the acupuncture needle is inserted; bruising; bleeding; worsening of lower back pain; and other pain (for example, pain in the leg and shoulder).
Therapeutic ultrasound for chronic low back pain
What is ultrasound therapy for treating low back pain?
Ultrasound therapy is the use of sound waves (vibrations) to treat pain. A healthcare provider rubs a hand‐held machine against the skin on the lower back. The machine produces vibrations that go through the skin. The aim is to deliver heat and energy to body parts under the skin, to reduce pain and speed up recovery.
Can therapeutic ultrasound help with chronic low back pain and does it have any unwanted effects?
- NICE does not recommend ultrasound for managing low back pain.
- Cochrane evidence on therapeutic ultrasound suggests that, compared to placebo:
- Ultrasound probably makes little or no difference to people’s well-being, and may have little to no benefit in helping people feel less restricted in their daily lives.
- The evidence is very uncertain about whether ultrasound reduces pain intensity or disability.
- Ultrasound may have little or no impact on unwanted effects.
Drug treatments for chronic low back pain
Can paracetamol help with chronic low back pain?
- NICE recommends that health professionals: “Do not offer paracetamol alone for managing low back pain”.
- There is a lack of evidence about paracetamol for treating chronic low back pain.
Can non-steroidal anti-inflammatory drugs (NSAIDs) help with chronic low back pain and what unwanted effects might NSAIDs have?
- NICE recommends that, when prescribing NSAIDs, health professionals should routinely monitor their use and prescribe them “at the lowest effective dose for the shortest possible period of time” because long-term use of NSAIDs may have risks.
- Cochrane evidence suggests that, compared with placebo, NSAIDs may:
- slightly reduce pain intensity and disability.
- may not increase the risk of unwanted effects in the medium term (between 3-12 months).
Can muscle relaxants and benzodiazepines help with chronic low back pain and what unwanted effects might they have?
- NICE does not mention the use of muscle relaxants and benzodiazepines in the context of managing chronic lower back pain on its own, but says “do not offer benzodiazepines for managing sciatica [pain in the lower back and leg caused by pressure on the sciatic nerve] as there is no overall evidence of benefit and there is evidence of harm”.
- Cochrane evidence suggests that, compared with a placebo:
- muscle relaxants and benzodiazepines may slightly increase the chance of pain relief.
- they may not increase the risk of unwanted effects. However, the evidence is of low certainty so the review authors cannot be confident in the result and future research may give a different picture.
Can opioids help with chronic low back pain and what unwanted effects might they have?
NICE recommends that health professionals “Do not offer opioids for managing chronic low back pain” given “the harms of prolonged use of opioids” – with potential harms outweighing potential benefits.
Weak opioids may be recommended for short-term use only – and only when an NSAID “is contraindicated [i.e. there is a specific reason why NSAIDs should not be given to a particular patient], not tolerated or has been ineffective”.
Cochrane evidence suggests that, compared with placebo:
- strong opioids probably slightly reduce pain intensity and disability;
- tapentadol slightly reduces pain intensity;
- tramadol may moderately reduce pain intensity and probably slightly reduces disability;
- buprenorphine may slightly reduce pain intensity (although the evidence is very uncertain) and may slightly reduce disability.
Compared with placebo, all types of opioids may slightly increase the risk of unwanted effects, such as feeling sick, headaches, constipation and dizziness.
Can antidepressants help with chronic low back pain and what unwanted effects might they have?
- NICE states “Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain”.
- Cochrane evidence suggests that:
- compared with placebo, antidepressants may have little to no impact on pain intensity or disability.
- There is not enough information about potential unwanted effects of antidepressants for treating chronic low back pain.
Other options recommended by NICE
- Manual therapy may be considered (this may involve spinal manipulation, mobilisation or soft tissue techniques such as massage – delivered by trained professionals), but only as part of a treatment package including exercise, with or without psychological therapy.
- Return-to-work programmes – focusing on helping people return to work and normal daily activities.
Other options not recommended by NICE
NICE states that the following are NOT recommended:
- Gabapentinoids or antiepileptic drugs.
- Orthotics – including ‘support’ belts or corsets, shoe inserts or shoes with rocker soles.
- Traction (manual ‘stretching’ of the spine).
- Electrotherapies including:
- Therapeutic ultrasound (discussed above).
- transcutaneous electrical nerve simulation (TENS) – which involves using a small battery‐operated unit to apply low‐intensity electrical current to the body using electrodes attached to the skin.
- percutaneous electrical nerve stimulation (PENS) – the procedure is similar to TENS, but involves inserting electrode needles underneath the skin.
- interferential therapy – which involves applying low-frequency electrical current to stimulate nerve activity.
Read more about managing back pain on the NHS website.
Join in the conversation with @CochraneUK @SarahChapman30 or leave a comment on the blog.
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Sarah Chapman and Selena Ryan-Vig have nothing to disclose.