Managing chronic back pain

A man in an exam room shows the person examining him where he is having back pain.

At some point, almost everyone experiences back pain. You may have strained a muscle while working out, lifting a heavy object, or simply bending over. Acute back pain (meaning a short-term episode) typically results from this kind of injury. It often resolves on its own with rest and the use of hot or cold compresses. You might be advised to take over-the-counter topical remedies and medication, such as acetaminophen (Tylenol) for pain relief or a nonsteroidal anti-inflammatory drug (NSAID) — such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn) — for both pain and inflammation.

However, chronic back pain (lasting more than 12 weeks) can be more challenging to diagnose and treat. “Finding the exact cause of chronic back pain can be tricky, as it could be related to many factors,” says Christopher Morin, a physical therapist with Harvard-affiliated Spaulding Rehabilitation Hospital. Here’s how the process works for diagnosing and treating chronic back pain.

Getting evaluated

The first step is a medical evaluation. Your doctor will ask about your symptoms and your medical history. They will examine your back muscles and spine and move you in specific ways to check for pain, muscle tenderness, weakness, stiffness, numbness, or abnormal reflexes.

Your doctor also may suggest additional testing, especially if they suspect a problem involving your spinal bones or nerves. Tests might include x-rays, a spinal MRI, a CT scan, or a PET scan; urine and blood tests; electromyography (which measures the electrical activity of muscles); or nerve conduction studies (which measure how well electrical signals travel along nerves).

There are many possible causes of chronic back pain. Besides an injury, common ones include fibromyalgia, degenerative disc disease, spondylitis (inflammatory arthritis of the spine), vertebral compression fractures caused by osteoporosis, and spinal stenosis.

Your treatment path for these conditions can vary. For all of them, however, you’ll most likely begin with conservative approaches to address the pain, typically over-the-counter pain relievers and physical therapy. Many people also use complementary treatments, such as acupuncture, chiropractic care, yoga, and massage therapy. Making lifestyle changes related to exercise, loss of excess weight, and diet is also beneficial (see “How lifestyle changes help with chronic back pain”).

In many cases, stress management techniques can help you deal with painful flare-ups. Depending on your diagnosis, your doctor may refer you to an orthopedic surgeon, a rheumatologist, or a pain specialist. “People may incorporate a combination of treatments to help manage their pain,” says Morin. “It’s often a trial-and-error approach, and you may have to experiment with it until you find something that works.”

If these approaches don’t work, the next steps involve stronger prescription medication, corticosteroid injections to temporarily reduce inflammation and relieve pain, specialized therapy, and, if necessary, surgery. Here’s a look at how these advanced treatments are used for specific conditions.

How lifestyle changes help with chronic back pain

Making lifestyle changes can help people manage chronic back pain. For instance, a study published in the September 2024 BMJ Open found that adding 20 minutes of moderate-to-vigorous activity and reducing sedentary time by 40 minutes every day helped keep back pain from getting worse. Similarly, losing excess weight can decrease pressure on the spine and reduce inflammation.

Adopting a diet rich in foods high in antioxidants, such as polyphenols, may help reduce inflammation and prevent flare-ups. These foods include many staples of the Mediterranean diet, such as whole fruits (especially berries), dark green leafy vegetables, nuts, legumes, and whole grains. Many of these foods are also rich in the micronutrients your immune system requires to function at a high level. Some research has suggested that omega-3 fatty acids, found in olive oil, flaxseed oil, and fatty fish (such as salmon, sardines, and mackerel), may also help control inflammation.

Fibromyalgia

This condition causes widespread pain and fatigue. In addition to the back, affected areas may include the trunk, neck, shoulders, knees, and elbows. Specific points on the body may be painful to the touch.

Treatment. The drugs duloxetine (Cymbalta), pregabalin (Lyrica), and milnacipran (Savella) are FDA-approved for fibromyalgia. Although low-dose amitriptyline (Elavil) is not specifically approved for this condition, doctors often prescribe it to reduce pain and improve sleep.

Degenerative disc disease

Degenerative disc disease, a natural part of aging, affects the discs between the bones in your spine (vertebrae). When a disc deteriorates, the inner part can push out and press on the spinal cord or a nearby nerve. This is known as a herniated or “slipped” disc. The disc can also become so worn out that the vertebrae begin to rub together. Bending and twisting often triggers back pain.

Treatment. Your doctor will likely prescribe one or more of a variety of medications. These include acetaminophen, an NSAID, duloxetine or another nerve pain medication, or muscle relaxants. They may also recommend a limited number of targeted corticosteroid injections. If symptoms worsen to the point where they interfere with daily activities, surgery can take pressure off the affected nerve roots. People tend to have the quickest recovery with minimally invasive approaches, such as a discectomy to remove the damaged portion of the disc pressing on the nerve.

Spondylitis

Spondylitis is a form of arthritis that causes inflammation and damage in the spine. In addition to back pain, spondylitis can cause pelvic and hip pain.

Treatment. If NSAIDs aren’t enough, the usual next step for addressing persistent inflammation is a biological agent to help control the disease, such as adalimumab (Humira, others) or infliximab (Remicade, others).

Osteoporosis

Weak bones due to osteoporosis do not cause pain. However, the condition increases the risk of a vertebral compression fracture, in which a bone in the spine collapses, leading to back pain.

Treatment. Besides pain medications, other potential therapies to help relieve pain from a vertebral compression fracture include temporary back bracing and calcitonin nasal spray or injections. To reduce the risk of future fractures, people with osteoporosis need to get enough vitamin D and dietary calcium and take steps to avoid falls. Several medications can help maintain bone density and even build bone.

Spinal stenosis

This condition involves narrowing of the spinal canal, which can compress the nerves and trigger pain, numbness, and weakness in the back and legs. Symptoms tend to worsen when you’re standing or walking but improve when you’re sitting or leaning forward.

Treatment. Doctors encourage people with spinal stenosis to remain active. Your doctor might prescribe stronger pain relievers and a muscle relaxant. Surgery is often reserved for people who have persistent or worsening symptoms or develop leg weakness.

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