Here’s something completely different for low back pain

Robert H. Shmerling, MD

Senior Faculty Editor, Harvard Health Publishing

Follow me on Twitter @RobShmerling

It’s a question that has challenged generations of patients and their doctors. The answer has changed over the years. When I was in medical school in the early 1980s, bedrest for a week or more was often recommended for severe back pain. This sometimes included hospital admission. Then, research demonstrated that prolonged bedrest was actually a bad idea. It was no better (and often worse) than taking it easy for a day or two followed by slowly increasing activity, including stretching and strengthening the back.

Medications, including pain relievers, non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants were a standard part of the initial treatment of back pain. But, recommendations released in February 2017 urge doctors to change their approach to back pain once again.

Didn’t I hear that NSAIDs don’t work well for back pain?

You did. A 2017 study found that NSAIDs did not work well for back pain. But, recommendations released that same year take that conclusion even further: it may be best to avoid medications altogether — at least at the start.

The American College of Physicians’ 2017  guidelines for the treatment of low back pain based on a review of more than 150 studies. The big news? Medications tend to have only temporary and modest benefits, so it makes sense to try something other than a pill. The specifics depend on the type and duration of back pain.

For new low back pain (lasting less than 12 weeks), try:

  • heat
  • massage
  • acupuncture
  • spinal manipulation, as with chiropractic care.

If these don’t work, NSAIDs or a muscle relaxant are reasonable options. But given their potential to cause side effects and their modest benefit, they aren’t the first choice.

For chronic low back pain (lasting 12 weeks or more), try:

  • exercise (including stretching, improving balance, and strengthening core muscles)
  • physical therapy
  • acupuncture
  • mindfulness-based programs intended to cope with or reduce stress.

Other approaches, such as tai chi, yoga, or progressive relaxation techniques may also be helpful.

If these don’t work, treatment with NSAIDs, tramadol, or duloxetine is worth consideration. However, opioids should be avoided for chronic low back pain in most cases.

It’s important to emphasize these suggestions are for low back pain that might begin after an unusually strenuous workout or shoveling snow. It’s not for serious causes of back pain such as a major injury, cancer, infection, or fractures (see “red flag” symptoms below).

What if the pain continues?

If pain persists despite these non-medication and medication-based treatments, your doctor may want to consider additional tests (such as MRI) or treatments. Remember, each person’s situation is a little different, and even medications that don’t work well on average, may work well for you.

You could see this coming?

It’s been known for years that the vast majority of low back pain goes away on its own, regardless of treatment. So, the challenge has been to find something that safely eases symptoms while waiting for improvement.

How do I know it’s nothing serious?

You don’t. But, you should be reassured that the numbers are with you. Ninety-nine percent or more of people with low back pain do not have a serious cause. But to help make sure your back isn’t in that small sliver of dangerous causes, doctors use the “red flag” questions:

  • Have you ever been diagnosed with cancer?
  • Have you experienced unexplained or unintentional weight loss?
  • Do you have an abnormal immune system (due to disease or medications)?
  • Do you use intravenous drugs?
  • Have you had a fever recently?
  • Have you had significant injury to your back recently?
  • Have you had bladder or bowel incontinence?

These questions and a physical examination are intended to identify factors that would increase the chances that your back pain is due to infection, tumor, or other serious cause.

So, what?

These guidelines endorse an approach to treating a common ailment that only a few years ago would have seemed outrageous. The remedies recommended are not brand new; but discouraging medication use as an initial step is a big departure from prior recommendations. An email alert I received just after these guidelines were published included the headline: “Take two yoga classes and call me next month?” It may not be such a bad idea!

Medical practice rarely changes right away, and these guidelines may have relatively little impact in the short run. But I would not be surprised if non-pharmacological treatment of back pain becomes the norm over time. Many of my patients already seek out these treatments regardless of whether I recommend them. After all, the “usual” medications for low back pain are not all that effective and often cause trouble. It’s time we recognize that there are other, better ways to help.



  1. Ocsar Jones

    Pain is inflammation.
    Inflammation is long term Magnesium deficiency.
    Recovery takes years. Better start soon.

  2. CScott

    Only Toradol & Prednisone gives some relief sometimes for a couple of hours or maybe 3months nothing more. Too much radiation isn’t good a matter of fact it can cause cancer. Stimulation gives temporary relief if they start at a 27 & there’s a possibility that high voltage may cause organ damage. Pills injection all are toxic & help one way & harm the other so whatever meds you take make certain you’re drinking plenty of water. No insurance no care what’s left to do live with the pain & pray the rest.

  3. Dr. Kai Tiltmann, DC

    Chronic Low Back Pain
    How We Get Hurt – Hidden Injuries

    Unfortunately and unwittingly, most people cause of their own low back pain. A lack of understanding of functional anatomy (how the back works), poor training, relying on outdated/incorrect information from the internet to under informed personal trainers, yoga instructors and medical providers (from chiropractors to surgeons), has left in its wake; chronic pain, disability, fear and unnecessary or incorrect treatment resulting in the greatest cause of world wide disability – low back pain.

    To be sure, not all low back pain is self induced. There are many reasons for the low back to hurt like having spinal metastatic diseases, spinal infection, abdominal aortic aneurism, ankylosing spondylitis, facet irritation, spondylolithesis or frank fracture at the vertebral end plates, pars, spinal process or compression fracture. These are all good reasons to seek medical intervention, or rather; medical intervention is required to diagnose these conditions. So if you have low back pain, it needs to be properly diagnoses and treated.

    These are not the conditions being discussed here. Low back pain caused by degenerative disc disease, disc herniation or discogenic pain, muscle strain or ligamentous injuries are often the result of poor low back use. When someone “throws out” their low back with a seemingly trivial movement (putting on socks), it was most likely a long time coming. Interestingly, sedentary individuals tend to have less low back pain compared to active people. Here is why. Too many people who exercise regularly, work manually, sit for work, or have active lifestyles, do so in ways that is injurious to their low back. They engage in poor postures, poor movement patterns or perform activities that will eventually lead to low back damage and pain. Once they are in pain, they will be treated, coached, instructed or go on-line to find “solutions”, which often prevent healing or worse, further degrade their condition. Sadly sometimes patients are told their pain is all in their heads and are dismissed outright.

    The low back best tolerates loads when the spine is in a neutral position. If the lumbar lordosis (low back curve) is maintained, during loading, the low back can tolerate enormous loads. Think of the deadlift. The form however, must be perfect or injury will occur. The movement occurs about the hips and not through the back.

    Poor low back mechanics will lead to back pain and disc injury that will feel like muscle pain and therefore treatment is often directed towards the muscles with; back stretches, anti-inflammatory medication, muscle relaxers, hamstring stretches etc. Many of these interventions will only aggravate the disc injury further.

    What are the movements and postures, which are not low back friendly? Here are a few:

    Exercises: Sit-ups (straight-leg, bent-knee), cross curl-up, crunches, elbow to knee, straight-leg raise, scissor kicks, superman, pelvic tilts, etc. Activities that requires forward bending or more accurately, forward lumbar flexion which causes the normal spinal lordotic curve to either straighten or reverse into a kyphotic curve increases the risk of disc bulging and low back pain.

    Yoga: There are many yoga poses that require forward bending beyond the capability of many. The key to not getting injured in yoga is to maintain the lumbar lordosis while forward bending, which requires flexion about the hips and not the back. Every movement is an opportunity to perform spine sparing movements or spine endangering movements. With enough time, and depending on how you use your back, you will either be fine or suffer from low back pain.

    Understanding how your back works, knowing what movements are spine sparing and which movements should be minimized or avoided will help reduce the likelihood of a back injury. Moving incorrectly is how most people cause their own low back pain. It is not that yoga or exercise is bad for the back, incorrect; yoga, exercises and postures are bad for the back and have lead to a worldwide low back pain pandemic.

    How do I address low back pain with my patients?
    I ensure that the patient has mechanical low back pain and not organic low back pain. For my low back sufferers, I generally do not provide chiropractic adjustments for the low back, but follow this plan of action.

    Plan of Action.

    1) Determine what movements or postures cause low back pain for each patient
    2) Eliminate the cause of pain and find pain free postures
    3) Develop postures and movement patterns that enable pain-free function
    4) Provide essential exercises to stabilize the torso, core and spine when moving through life
    5) Develop a walking plan and exercise plan
    6) Mobilize the hips
    7) Make daily use of exercises based on patterns of movements: push, pull, carry, etc.
    8) Make healthy spine choices when engaging in any activity

    Dr. Kai Tiltmann, DC
    Clinic Director

    Financial District Chiropractic

  4. Arthur Sands MD

    I have treated over several hundred patients with chronic low back pain using an inversion table – ~70% have complete or substantial improvement !! it works – have used it myself with excellent results !

    (note contraindications)

    Art Sands MD

  5. Nancy Fox

    This article is all old news. Basically common sense as far as just an aching back but these ideas are fine if it is muscular but if it is disease this article is useless. Very disappointed in Harvard help.

  6. Ellen Welter

    This is great piece to make individuals aware that back pain does not resolve with medication and there are other options to help. It lists physical therapy as a treatment option among many other things, however as a orthopedic manual therapy (OMT) trained physical therapist, it has been frustrating to see physical therapy listed as a “treatment” for low back pain along with spinal manipulation, heat, massage, acupuncture, exercise and mindfulness. Physical Therapy is not simply a modality to be delivered, but rather the health care profession that encompasses the assessment and treatment of the musculoskeletal system. A physical therapist utilizes all of those approaches listed and more to treat both acute and chronic low back pain; depending on the etiology and subsequent symptoms.

    It would be great to see the medical doctors embrace us as the experts in the assessment and treatment of the musculoskeletal system!

    • John Sasso

      That may be true for you. In my experience, as a referring physician, most PTs don’t practice in that sort of ‘extended-scope’ practice. There are many individuals in a variety of disciplines that are ‘experts in the assessment and treatment of the musculoskeletal system’ as you say (i.e Physiatrists, Chiropractors, PTs, Orthopedists, ATCs, CMTs.. and on and on). It just depends on the individual professionals training, experience, and philosophy of practice. My assumption (though that is bad) is that you are very well rounded in your experience and means of assessment and treatment. This is great. My point is only to present that there are many other health care professionals that share the same diversity of assessment and treatment (based on the individual – not the profession) with slightly different primary approaches of treatment. Be well.

      • Ellen Welter

        To your point, I couldn’t agree more that the assessment and quality of care depends on each individuals personal training. In the field of physical therapy, all of the treatments this article listed are within the standard of practice for physical therapists and are part of our basic doctor of physical therapy degree. However, as in every profession there are better trained practitioners as compared with others and there are several ways to be educated about referral sources, so your patients receive quality, manual physical therapy from well trained physical therapists. When we refer out to other PTs, we look for those that carrying a clinical certification or therapists who have completed a residency or fellowship training, not just those that claim to perform “manual therapy”. These credentials are as follows, COMT (Certified Orthopedic Manual Therapist), FAAOMPT (Fellow of the American Academy of Orthopedic Manual Physical Therapists), CMPT (Certified Manual Physical Therapist). I’d be happy to help you network with some therapists in your geographic area or anyone else, if interested.

  7. david x

    That’s right, finally: don’t start out with a medication. The pharmaceutical industry has pretty much brainwashed both patients and their physicians into treating every issue or ailment with a drug.

    NSAIDs just had their warning for heart problems increased by the F.D.A. This increased warning is a rare thing. But look on the shelves at your pharmacy. Not much in the way of warnings on the shelves and shelves and shelves of NSAIDs.

  8. Anna

    As a sufferer of back pain for more than 20 years…..the formula afforded is too simplistic. I never went to doctor until over the counter, exercise, and a myriad of other things tried. I agree…if cant get a handle on pain get an mri and figure out root cause before attempting something that might make things worse. My latest solution….epidural injections to bring inflamation down and physical therapy. A good masseuse a d reflexology are very helpful.

  9. T Stanley

    I’m 64, active, 5’10”, 168 lbs. I strained my back 8 months ago by improperly lifting something way too heavy. The problem slowly resolved, but then I started to get lower back pain. I took a trip and my back got better. When I returned home the back pain began to return. One morning it was nearly impossible to get to the toilet. I tried chiropractic, massage, saw my physician, had several sessions of physical therapy, even tried a little lumbar traction. I had some improvement but still experienced pain. FINALLY I decided to try something radical. I slept on a futon on a carpeted floor. After 3-7 days virtually all my back pain was GONE. I’m still sleeping on the floor. At some point I’ll buy a new mattress. There’s no downside risk of trying this … unless your spouse steps on you in the middle of the night !

  10. Melissa

    I’ve found an all natural pill called formula 303 which has helped me significantly. I had a back injury at work and at first the pain was only in my low back and in about a week in a half it then moved all the way down my flute, my leg and into my foot. My insurance is terrible! I did not send it through workmans comp because I do not wish to be known as that person. Many people in my state lie and try to milk things they don’t need or deserve. So I took the expense on my own. I also had to quit the job because it was making my back worse. So now I have medical expenses with no income. Not a good combination. I’ve been to chiropractor and two osteopaths. I’m not willing to do surgery as research has shown many who do are in no better spot a year later or some even worse than those who do not get surgery. I do not wish to take pain medication as I want to know what’s going on with my body and not become addicted to or depend on pills. My chiropractor recommended I try this all natural pill. No side affects. I didn’t think it would do anything but on days when I’m having a real hard time moving I take two and it makes a huge difference.

  11. Dr Shikha S Parmar

    Please include LOW LEVEL LASER THERAPY (LLLT) in your advice for the management of low back pain. You article is entitled “New approach to back pain treatment” and references the American College of Physicians new guidelines which include LLLT. But your article omits to mention this treatment and educate your patients on it. The advice in your article is not new at all and just mentions all the usual treatment modalities that patients have already tried and often failed in their quest for a solution to back pain. Sufferers are truly seeking novel approaches to treatment and LLLT deserves a much higher profile.
    Low Level Laser Therapy is established with over 40 years of use globally. It is scientifically proven, evidence-based and extensively backed by research by scientists world-wide including Harvard University’s own  Professor Michael Hamblin. It is safe and highly effective in not only addressing the pain but also addressing the inflammation underlying and causing the pain leading to resolution of pain and dysfunction. Acupuncture is still questionable in its efficacy and how it actually works is not explained by science. LLLT is both backed by good solid science and also clinical trials. Even the World Health Organisation endorses and recommends LLLT for neck pain.
    I am a conventional medical doctor (primary care/family physician) offering this non-invasive treatment for the past 6 years in Australia with excellent results. I have nothing personal to gain from promoting LLLT in this forum except to educate your audience directly and encourage them to seek knowledge and information about this non-invasive highly effective treatment modality. LLLT addresses the underlying cause of back pain restoring healthy tissues and enabling sufferers to engage meaningfully and pain-free in an exercise rehab program to strengthen their backs and therefore prevent future occurrences and also get off unhelpful and unsafe pain medications. All too often sufferers are in too much pain to undertake exercise. LLLT appears in the latest American College of Physician Guidelines and deserves a mention in this article.

    • Ruth Rastogi

      My sister had severe back pain for many years .At times she was absolutely immobilized. She tried lots of things and finally found Dr John Sarno. She realized that her pain was due to stress from certain childhood issues.
      I gave Dr Sarnos book to a friend who was in traction for back pain. he realized it was due to family stress , worked thru his issues and became pain free.
      Of course there will be some people who have physical issues , but when physical issues are eliminated we need to start thinking about modern day stress.

      She cried and cried all night and by morning the pain was gone. It did occasionally return but she now knew how to deal with it. she also went to Recovery meetings for anxious people and did Yoga and lots of exercise

  12. Stephen

    Active care is it. As a chiropractor I used to see people in the 80’s who did the bed rest for a week and ongoing that take drugs that address the fall out from functional problems but not the causes. Pain relievers, anti-inflammatories and muscle relaxants all have a far worse safety record than an adjustment and properly prescribed exercise to target dysfunctional movements and segmental spinal levels. After decades of insistence that these were the way to go it is now conceded to be inappropriate.
    With acute problems I recommend ice. Heat as recommended here will promote inflammation and in the acute stages you already have too much of it. Yoga can be great but how many instructors try to get people to do inappropriate movements such as, folding their upper body out over their lower body by bending at the hips and spine putting the persons back in a position almost guaranteed to create disk pressure that can promote a disk bulge and sciatic nerve root impingement. Truly the biomechanical problem should be understood (physical exam) and specifically treated.
    Symptoms often go away without treatment but do the arthritic changes associated with poor movement and function progress? So it recurs. Often! Narrowing of the holes where the nerves come out (IVF’s) and the spinal canal that holds the spinal cord greet a person as they enter their 40’s 50’s and 60’s. These things don’t enhance life!
    So, there are lots of ways but your spine should be assessed and understood for its strengths and weaknesses and taken care of appropriately.

  13. Maria Welch

    What about floatation therapy? This is extremely effective for back pain and has no side effects. While floating in 1000+ pounds of Epsom Salt dissolved in skin temperature water, you are completely supported with no pressure or stress on the spine, joints or muscles. It also provides a natural traction for the spine which is very helpful for sciatica and spinal compression issues.

  14. Mary

    What about stenosis? Are your recommendations the same?

  15. Arnold Dill

    Spot on from my 48 year expereince with a hernitated disk L5. Just takes time to heal, manage. My spouse has been on back drugs forever and had 4 back fusions and numerous back injections at Emory Orthopedics, the last an 8.5 hr. surgery — all a complete failure unfortunately and huge expense. If followed, this article could save 10s of billions in drug/medical expenses.




    • Parikh HC

      Why not just try meditation and yoga asans, under guidance.
      Jay jinendra.

    • Sybil Dean

      What do you mean be ‘crumbling’?
      Osteoporosis (Brittle Bones)?
      Kind regards, Sybil

    • CScott

      Ms. Arlene. It gets worse I fell down 4 concrete steps in 97 went to a walk in clinic in which they took xrays nothing broken & some pain meds Which I took for 2 days & back to work no more problems until 5years later My God did it revisit me in a bad way to make a long story short it caused me to bear about 11 yrs of therapy that also includes stimulation which gave me about an hour or two relief & that is if they started the voltage at 27. Under 5 specialist care which I no longer receive since my job fired me for being out forget about disability they only give help to alcolholics & drug abusers but I do advise you to get you a lawyer for that slip & fall which I regret I did not do and of course stress adds to the C567 herniated disks spinal stenosis migraines sciatic nerve damage loss of feelings in left arm lower back & shoulder pain pin sensation & numbness in hands & feet that never goes away & sudden electric shocks in legs ostephytes which are bone spurs striking spinal nerves also has develop in my hands limiting me in so many ways including standing sitting lying down I can go on but I won’t just know it doesn’t get better esp. If you don’t have medical insurance & free clinics that’s another conversation take care of yourself dearest & again get a lawyer.

  17. char

    In my opinion you should start with an X-ray or MRI before any of the
    treatments recommended so that you know that none of the suggested treatments could make it worse and cause real damage. I have seen this happen in my 50 years as a nurse. You also need to mention
    if there is pain going down the leg which could be sciatica.

  18. Sam Rifai

    I am 66 years old. From my low back pain experience , I did found out the best thing is to stay active and continue your daily life without any medication . Exercise , Exercise and Continue exercising . Try to apply the back pain exercise to strength your back

  19. Robby

    I am happy to see this from Harvard. I hope that yoga, exercise classes, therapy pools, nutrition help, etc will somehow or other become typical practice included in our insurance coverage to be used at health organizations. At a minimum, give intro sessions to help people get started on the right road or reduced charges.
    And as patients, most of us need to think hard about a new smart phone when that same money could go toward good health.

  20. Julia

    I’m experiencing Very VERY Good Results with Gabapentin Medication – it’s allowing me to be more productive – Yet – My Body then requires Rest for a couple of days to recover from the activity.

  21. Marc Schaeffer

    The article should have included whether or not back pain radiates into the leg as a “warning sign” that further and earlier investigation is warranted.

  22. azure

    How many insurance policies pay for yoga classes, and/or acupuncture, and/or mindfulness based stress reduction programs, or massage?
    As compared to how many pay for at least some of the cost of pain medications?

    Some people, quite a few people, can’t afford to pay for these “better” treatments out of pocket. What is Harvard Medical School, faculty (who may accept funding from bigPharma for research, etc), administrators et al doing to change that?

    Be nice to hear about more MDs, DO, et al who deal with what is reality for more and more people in the US.

    • Mary

      A very cogent response. I’ve recently been given exactly this advice by a spine doctor for chronic lower back pain, and as a result have in the past 2 months spent $1,200 out of pocket. This is supposed to be long-term management for me (except for the PT, for which I only pay a co-pay, but which ends in a month). My Tufts health insurance covers none of it.

      At the very least specialists in spine problems and pain management should acknowledge that the best practice advice is not affordable to most people and not covered by insurance (for those of us who will still have any after Congress is through with its “reform”).

    • Edda

      You can do yoga and simple core strengthening exercises at home . You can even do self massage. Don’t exaggerate. If you don’t how to do it just check online.

  23. Kanyakumari Roychowdhury

    Thanks for the information provided in this article. This article might help people suffering from low back pain to take a better decision as a choice of treatment.

  24. Joe

    Is this information the same for arthritis in the spine and sciatica nerve pain?

  25. Christopher Binns

    This may not make pharma happy but I am glad you shared this research with us. It’s about time medical professionals uphold ethics over profit. I will be sure to share this article. Thank you.

    • JimJ

      90 tablets 800mg Generic Ibuprofen $ 12 @3 tablets a day. Personally I don’t think pharma will shed a tear for this.
      1 Yoga class @ $ 10 per hour. How many yoga classes to take? One per week? Two or maybe three? You make the math…
      And what’s next, a trip to Lourdes for painrelief? Will probably also have a benificial effect 🙂

Commenting has been closed for this post.