If you have had lower back pain, you are not alone. Back pain is one of most common reasons people see a doctor or miss days at work. Even school-age children can have back pain.

Back pain can range in intensity from a dull, constant ache to a sudden, sharp or shooting pain. It can begin suddenly as a result of an accident or by lifting something heavy, or it can develop over time as we age. Getting too little exercise followed by a strenuous workout also can cause back pain.

There are two types of back pain:

• Acute, or short-term back pain lasts a few days to a few weeks. Most low back pain is acute. It tends to resolve on its own within a few days with self-care and there is no residual loss of function. In some cases a few months are required for the symptoms to disappear.
• Chronic back pain is defined as pain that continues for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. Even if pain persists, it does not always mean there is a medically serious underlying cause or one that can be easily identified and treated. In some cases, treatment successfully relieves chronic low back pain, but in other cases pain continues despite medical and surgical treatment.

Back pain is one of the most common medical problems in the United States. It can range from a dull, constant ache to a sudden, sharp pain. Sometimes it can come on suddenly – from an accident, a fall, or lifting something heavy, or it can develop slowly because of age-related degenerative changes to the spine. In some cases, inflammatory disorders or other medical conditions cause back pain.

Treatment varies depending on the cause and symptoms; however, there are steps you can take to improve your health and lower your chance of developing chronic or long-lasting back pain.

Understanding the Anatomy of the Back

There are many different structures in the anatomy of the back that work together to support your body. Problems with any one of these structures can cause back pain.

• There are four regions of the spine:
  • Cervical spine.
  • Thoracic spine.
  • Lumbar spine.
  • Sacrum and coccyx.

• Parts of the spine and back include:
  • Vertebrae – small bones stacked on top of one another, which protect the spinal cord.
  • Spinal cord – long bundle of nerves that run down the back through a canal in the vertebrae.
  • Intervertebral discs – cushion-like pads between the vertebrae that act like shock absorbers and spacers for the spine.
  • Ligaments – short bands of tough, flexible tissue that hold the vertebrae in place.
  • Tendons – cord of tissue that connects muscle to bone.
  • Muscles – a bundle of dynamic fibers that support your spine and upper body and help you move.

Back pain is one of most common reasons people see a doctor or miss days at work. Back pain can range in intensity from a dull, constant ache to a sudden, sharp or shooting pain. There are two types of back pain:

• Acute (short-term) back pain lasts a few days to a few weeks. It usually resolves on its own within a few days with self-care and there is no long-term loss of function.
• Chronic back pain is pain that continues for 12 weeks or longer, even after an initial injury or underlying cause of back pain has been treated.

Risk factors for low back pain

• Age: The first attack of low back pain typically occurs between the ages of 30 and 50 and may become more common as you age.
• Fitness level: Back pain is more common among people who are not physically fit, as their muscles may not properly support the spine.
• Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on your back and cause pain.
• Genetics: Some causes of back pain, such as ankylosing spondylitis (a form of arthritis that affects the spine), have a genetic component.
• Job-related factors: Job that requires heavy lifting, pushing or pulling, or twisting or vibrating the spine can injure your back, as can sitting at a desk all day, especially if you have poor posture or sit in a chair with not enough back support.
• Mental health: Anxiety, mood, and depression can influence how you perceive your back pain and stress can cause muscle tension.
• Smoking: This can restrict blood flow and oxygen to your discs, causing them to degenerate faster.
• Backpack overload in children: A backpack overloaded with schoolbooks and supplies can strain the back and cause muscle fatigue.

Recommendations for keeping your back healthy

• Avoid movements that jolt or strain your back.
• Exercise regularly to keep your muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
• Maintain a healthy weight and eat a nutritious diet that promotes new bone growth.
• Use ergonomically designed furniture and equipment at home and at work.
• Switch sitting positions often and periodically walk around the office or gently stretch your muscles to relieve tension. Put your feet on a low stool or a stack of books when sitting for a long time.
• Wear comfortable, low-heeled shoes.
• Sleeping on your side with your knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.    
• Don't try to lift objects that are too heavy. Lift from the knees, keep a straight back, and objects close to the body.    
• Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.

Anyone can have back pain. Factors that can increase the risk for low back pain include:

Age: The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes more common with advancing age. Loss of bone strength from osteoporosis can lead to fractures, and at the same time, muscle elasticity and tone decrease. The intervertebral discs begin to lose fluid and flexibility with age, which decreases their ability to cushion the vertebrae. The risk of spinal stenosis also increases with age.

Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine. “Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise can help maintain the integrity of intervertebral discs.

Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the back and lead to low back pain.

Genetics: Some causes of back pain, such as ankylosing spondylitis (a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine), have a genetic component.

Job-related factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when it involves twisting or vibrating the spine, can lead to injury and back pain. Working at a desk all day can contribute to pain, especially from poor posture or sitting in a chair with not enough back support.

Mental health: Anxiety and depression can influence how closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can contribute to the development of such psychological factors. Stress can affect the body in numerous ways, including causing muscle tension.

Smoking: It can restrict blood flow and oxygen to the discs, causing them to degenerate faster.

Backpack overload in children: A backpack overloaded with schoolbooks and supplies can strain the back and cause muscle fatigue.

Psychological factors: Mood and depression, stress, and psychological well-being also can influence the likelihood of experiencing back pain.

Most acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Some examples of mechanical causes of low back pain include:

Congenital

• Skeletal irregularities such as scoliosis (a curvature of the spine), lordosis (an abnormally exaggerated arch in the lower back), kyphosis (excessive outward arch of the spine), and other congenital anomalies of the spine.
• Spina bifida which involves the incomplete development of the spinal cord and/or its protective covering and can cause problems involving malformation of vertebrae and abnormal sensations and even paralysis.

Injuries

• Sprains (overstretched or torn ligaments), strains (tears in tendons or muscle), and spasms (sudden contraction of a muscle or group of muscles)
• Traumatic Injury such as from playing sports, car accidents, or a fall that can injure tendons, ligaments, or muscle causing the pain, as well as compress the spine and cause discs to rupture or herniate.

Degenerative problems

• Intervertebral disc degeneration which occurs when the usually rubbery discs wear down as a normal process of aging and lose their cushioning ability.
• Spondylosis the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older.
• Arthritis or other inflammatory disease in the spine, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae.

Nerve and spinal cord problems

• Spinal nerve compression, inflammation and/or injury
• Sciatica (also called radiculopathy), caused by something pressing on the sciatic nerve that travels through the buttocks and extends down the back of the leg. People with sciatica may feel shock-like or burning low back pain combined with pain through the buttocks and down one leg.
• Spinal stenosis, the narrowing of the spinal column that puts pressure on the spinal cord and nerves
• Spondylolisthesis, which happens when a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column
• Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward
• Infections involving the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
• Cauda equina syndrome occurs when a ruptured disc pushes into the spinal canal and presses on the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
• Osteoporosis (a progressive decrease in bone density and strength that can lead to painful fractures of the vertebrae)

Non-spine sources

• Kidney stones can cause sharp pain in the lower back, usually on one side
• Endometriosis (the buildup of uterine tissue in places outside the uterus)
• Fibromyalgia (a chronic pain syndrome involving widespread muscle pain and fatigue)
• Tumors that press on or destroy the bony spine or spinal cord and nerves or outside the spine elsewhere in the back
• Pregnancy (back symptoms almost always completely go away after giving birth)

A complete medical history and physical exam can usually identify any serious conditions that may be causing the pain. Neurologic tests can help determine the cause of pain and appropriate treatment. Imaging tests are not needed in most cases but may be ordered to rule out specific causes of pain, including tumors and spinal stenosis. Occasionally the cause of chronic lower back pain is difficult to determine even after a thorough examination.

Tests include:

Blood tests are not routinely used to diagnose the cause of back pain but might be ordered to look for signs of inflammation, infection, cancer, and/or arthritis.

Bone scans can detect and monitor an infection, fracture, or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones, particularly in areas with some abnormality. Scanner-generated images can identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

Discography involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection.

Electrodiagnostics can identify problems related to the nerves in the back and legs. The procedures include:

• electromyography (EMG) assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
• evoked potential studies involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.
• nerve conduction studies (NCS) also use two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage.

Diagnostic imaging tests allow specialists to see into the body without having to perform exploratory surgery. Imaging includes:

• Computerized tomography (CT) can show soft tissue structures that cannot be seen on conventional x-rays, such as disc rupture, spinal stenosis, or tumors.
• Magnetic resonance imaging (MRI) creates a computer-generated image of bony structures and soft tissues such as muscles, ligaments, tendons, and blood vessels. An MRI may be ordered if a problem such as infection, tumor, inflammation, disc herniation or rupture, or pressure on a nerve is suspected
• X-ray imaging can show broken bones or an injured or misaligned vertebra.

Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray or CT scans.

Acute back pain usually gets better on its own. Acute back pain is usually treated with:

• Medications designed to relieve pain and/or inflammation
  • analgesics such as acetaminophen and aspirin
  • non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen may be sold over the counter; some NSAIDS are prescribed by a physician
  • muscle relaxants are prescription drugs that are used on a short-term basis to relax tight muscles
  • topical pain relief such as creams, gels, patches, or sprays applied to the skin stimulate the nerves in the skin to provide feelings of warmth or cold in order to dull the sensation of pain. Common topical medications include capsaicin and lidocaine.
• Heat and/or ice may help ease pain, reduce inflammation, and improve mobility for some people
• Gentle stretching (not vigorous exercise) upon advice by your healthcare professional

Exercising, bed rest, and surgery are typically not recommended for acute back pain.

Chronic back pain is most often treated with a stepped care approach, moving from simple low-cost treatments to more aggressive approaches. Specific treatments may depend on the identified cause of the back pain.

Step 1 Early treatments

Medications may include:

• Analgesics and NSAIDS
• Opioid drugs prescribed by a physician (opioids should be used only for a short period of time and under a physician’s supervision, as opioids can be addictive, aggravate depression, and have other side effects)
• Anticonvulsants—prescribed drugs primarily used to treat seizures—may be useful in treating people with sciatica
• Antidepressants such as tricyclics and serotonin, and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain (prescribed by a physician)

Self-management:

• Hot or cold packs
• Resuming normal activities as soon as possible may ease pain; bed rest is not recommended
• Exercises that strengthen core or abdominal muscles may help to speed recovery from chronic low back pain. Always check first with a physician before starting an exercise program and to get a list of helpful exercises.

Step 2 Complementary and alternative techniques include:

• Acupuncture is moderately effective for chronic low back pain. It involves inserting thin needles into precise points throughout the body and stimulating them (by twisting or passing a low-voltage electrical current through them), which may cause the body to release naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine.
  • Behavioral approaches include:
  • Biofeedback involves attaching electrodes to the skin and using an electromyography machine that allows people to become aware of and control their breathing, muscle tension, heart rate, and skin temperature; people regulate their response to pain by using relaxation techniques
  • Cognitive therapy involves using relaxation and coping techniques to ease back pain
• Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device which places electrodes on the skin over the painful area that generate electrical impulses designed to block or modify the perception of pain
• Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combination with other interventions
• Spinal manipulation and spinal mobilization are approaches in which doctors of chiropractic care use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. The techniques may provide small to moderate short-term benefits in people with chronic low back pain but neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.

Spinal injections include:
Trigger point injections can relax knotted muscles (trigger points) that may contribute to back pain. An injection or series of injections of a local anesthetic and often a corticosteroid drug into the trigger point(s) can lessen or relieve pain.

Epidural steroid injections into the lumbar area of the back are given to treat low back pain and sciatica associated with inflammation. Pain relief associated with the injections tends to be temporary and the injections are not advised for long-term use.

Radiofrequency ablation involves inserting a fine needle into the area causing the pain through which an electrode is passed and heated to destroy nerve fibers that carry pain signals to the brain. Also called a rhizotomy, the procedure can relieve pain for several months.

• Traction involves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction but the back pain tends to return once the traction is released.

Step 3 More advanced care options

Surgery
When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. However, surgery is not always successful. It may be months following surgery before the person is fully healed and there may be permanent loss of flexibility. Surgical options include:

• Vertebroplasty and kyphoplasty for fractured vertebra are minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. A glue-like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce spinal deformity.
• Spinal laminectomy (also known as spinal decompression) is done when a narrowing of the spinal canal causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae are removed, along with any bone spurs, to relieve pressure on the nerves.
• Discectomy and microdiscectomy involve removing a herniated disc through an incision in the back (microdiscectomy uses a much smaller incision in the back and allows for a more rapid recovery). Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
• Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can narrow the space where the spinal nerve exits and press on the nerve. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
• Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves.
• Radiofrequency denervation uses electrical impulses to interrupt nerve conduction (including pain signaling). Using x-ray guidance, a needle is inserted into a target area of nerves and the region is heated, which destroys part of the target nerves and offers temporary pain relief.
• Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
• Artificial disc replacement is an alternative to spinal fusion for treating severely damaged discs. The procedure involves removing the disc and replacing it with a synthetic disc that helps restore height and movement between the vertebrae.
• Interspinous spacers are small devices that are inserted into the spine to keep the spinal canal open and avoid pinching the nerves. It is used to treat people with spinal stenosis.

Implanted nerve stimulators

• Spinal cord stimulation uses low-voltage electrical impulses from a small implanted device that is connected to a wire that runs along the spinal cord. The impulses are designed to block pain signals that are normally sent to the brain.
• Dorsal root ganglion stimulation also involves electrical signals sent along a wire connected to a small device that is implanted into the lower back. It specifically targets the nerve fibers that transmit pain signals. The impulses are designed to replace pain signals with a less painful numbing or tingling sensation.
• Peripheral nerve stimulation also uses a small implanted device and an electrode to generate and send electrical pulses that create a tingling sensation to provide pain relief.

Rehabilitation programs
Rehabilitation teams use a mix of healthcare professionals from different specialties and disciplines to develop programs of care that help people live with chronic pain. The programs are designed to help the individual reduce pain and reliance on opioid pain medicines. Programs last usually two to three weeks and can be done on an in-patient or out-patient basis.

Painkillers are only recommended in addition to active treatments such as exercises and movement – for example, to relieve severe back pain or to help you start moving more again. Because of the associated risks, though, they shouldn't be used over a long period of time.

Low back pain usually goes away on its own after a while. In most cases it's not clear what's causing the pain. It is then called "non-specific" back pain. If low back pain lasts a long time or keeps returning, it is often difficult to treat. Good-quality studies have so far found that only few treatments help. Staying active and moving enough are among the most effective things you can do yourself.

The medications used include over-the-counter and prescription painkillers, muscle relaxants and antidepressants. Because medication can have side effects – especially when taken over longer periods of time – it shouldn't be taken continuously, but rather only for a short while, for example when the pain is especially severe. What's more, painkillers only have a limited effect in the treatment of non-specific low back pain.

Over-the-counter painkillers

Non-steroidal anti-inflammatory drugs (NSAIDS) such as diclofenac, ibuprofen and naproxen are the most commonly used medications for low back pain. They can often relieve the symptoms a little. Lower doses of these drugs are available without a prescription. NSAIDs can be taken as tablets or injected into muscle tissue. Injections aren't recommended nowadays, though, because they can cause bleeding or inflammation where the needle enters the skin. In rare cases they can also lead to serious complications such as abscesses or nerve damage.

NSAIDs can cause stomach ache and – if taken over long periods of time – increase the likelihood of developing a stomach ulcer. They also slightly increase the risk of developing certain heart problems. People who have kidney failure should talk to their doctor before taking NSAIDs. Because of the possible side effects, it's a good idea to carefully consider the pros and cons of the medications, make sure you don't take them for too long, and use them correctly.

Two other anti-inflammatory painkillers that have a similar effect are two COX-2 inhibitors called celecoxib and etoricoxib (also referred to as coxibs). These medications are not approved for the treatment of back pain, so they are only rarely used – for instance, if opioids are the only other option.

Acetaminophen (paracetamol)

The painkiller acetaminophen (paracetamol) is also sometimes used to treat low back pain. But studies have shown that it is no more effective than a placebo (fake medication).

When using this painkiller, it's important to make sure you take the right dose. An overdose of acetaminophen can damage the liver and also cause liver failure. So experts recommend not taking more than 4 grams (4,000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. When taken at the right dose, though, acetaminophen is well tolerated. It is not suitable for people with liver problems.

Metamizole ("Novalgin")

Metamizole is a fever-reducing and anti-inflammatory painkiller that is similar to the NSAIDs. Although it is often used for the treatment of low back pain, there are no studies on its effectiveness in this area. Medical societies consider it to be an alternative to opioids for severe low back pain.

The use of metamizole is controversial because it can have a rare but very serious side effect called agranulocytosis, where the number of certain types of white blood cells decreases so much that it can become life-threatening. Possible signs of agranulocytosis include fever, a sore throat and inflamed mucous membranes. But the risk of this side effect is estimated to be much less than 0.1%. Metamizole is prescription-only in Germany.

Opioids

If other treatments don't work well enough, low back pain can be treated with stronger, prescription-only painkillers known as opioids. The best-known opioid is morphine. Other opioids include buprenorphine, codeine, hydromorphone, oxycodone, tapentadol, tilidine and tramadol. Opioids vary in their strength. Morphine, for example, is a very strong opioid, while tramadol is a weaker one. They are also available as skin patches.

Opioids are very effective at relieving many different types of acute pain. But they aren't as good at relieving low back pain as commonly believed. In studies, opioids were shown to relieve the pain in only about 10 out of 100 people. They usually don't work any better than NSAIDs do.

Opioids can have side effects such as constipation, nausea, decreased sex drive, dizziness and tiredness, affecting your ability to drive vehicles. There is also a small risk of a life-threatening overdose. So it is very important to follow the doctor's instructions and not to increase the dose without talking to the doctor first. This is also true for skin patches containing opioids (e.g. fentanyl patches). People can become physically dependent on opioids too. According to studies in this area, it is estimated that this happens to about 6% of all people who use opioids over a long period of time.

Treatment with opioids is an option if other treatments haven't helped enough or if NSAIDs can't be used. Opioids generally shouldn't be used for longer than 12 weeks. If you use opioids, it can be a good idea to seek advice from a pain specialist who has a lot of experience with these drugs.

Muscle relaxants

Muscle relaxants are thought to relieve pain by reducing tension in the muscles. They are usually prescription-only sedatives that influence the central nervous system.

Muscle relaxants can relieve acute back pain in the short term. But they haven't been proven to help relieve chronic low back pain.

Muscle relaxants can have side effects like drowsiness or dizziness. This can affect your ability to drive, and also increase the risk of falls in older people. Taking these medications can be a problem for people who operate machinery, too. Muscle relaxants known as benzodiazepines can be addictive as well.

Due to these side effects, medical societies in Germany do not recommend using muscle relaxants for the treatment of back pain.

Antidepressants

Antidepressants are prescription-only drugs used to treat depression. Some of these medications have also been approved for the treatment of chronic pain. Most antidepressants haven't been proven to help in chronic low back pain. One exception is the drug duloxetine, which can relieve the symptoms a little.

Antidepressants have a number of side effects, including loss of appetite, nausea, a dry mouth and low blood pressure. They can reduce sexual desire too. Medical societies in Germany do not recommend using antidepressants for the treatment of back pain.

Treatment with injections

If other treatments don't help relieve low back pain, treatment with injections is often offered. This involves injecting various pain-relieving or numbing medications, including the following:

• Local anesthetics

• Steroids

• Botulinum toxin (Botox)

Some of these medications aim to stimulate the body’s natural healing processes if the problem is being caused by irritated nerve roots, tendons and ligaments, or to reduce inflammation or numb the pain. Different drugs are injected into different places: for instance, into muscle tissue, into the tissue directly surrounding nerves, ligaments or spinal disks, into the joints of the spine, or into a space in the spinal canal known as the epidural space.

There is no good-quality research on the effectiveness of the various kinds of injections in the treatment of non-specific low back pain. Although side effects are rare, they can lead to serious complications. For example, if an anesthetic is injected into the wrong place it can cause respiratory paralysis, making it hard to breathe. Injections near the spine can also lead to infections.

Because it's not clear how effective they are and because of the possible risks, it's not a good idea for people with non-specific low back pain to have treatment with injections. Medical societies in Germany do not recommend injections for this purpose.

Understanding Your Condition

What is low back pain?

Low back pain may be dull and aching or sharp and stabbing. The pain may be mild or severe, and you may feel tingling or burning. You may also have pain in your legs.

You may feel stiff, and it may be hard to stand up straight or move your lower back. Low back pain can make it hard to do your daily activities.

• Acute low back pain lasts for 4 weeks or less
• Subacute low back pain lasts between 4 weeks and 12 weeks
• Chronic low back pain lasts for 12 weeks or longer

Often, it is hard to know the exact cause of low back pain. There are many possible causes. One possible cause is a strain or tear in the muscles or ligaments that support your back. Low back pain can also be caused by a muscle spasm in your back.

Your health care professional may talk with you about your history of low back pain and may do a physical exam. Both can help rule out any serious conditions that may be causing your low back pain (such as cancer or an infection of the spine or kidneys).

Understanding Your Options

How is low back pain treated?

There are many treatment options for acute, subacute, and chronic low back pain.

• Medicine: Your health care professional may suggest a medicine to reduce pain and swelling or to relax your muscles.
  • Most medicines are taken by mouth, but some are given as a shot or through an IV (intravenous) tube in your arm.
  • Some medicines are available over the counter, and for some you need a prescription.
• Nonmedicine treatments: Your health care professional may also suggest nonmedicine treatments such as heat, exercise, or massage.

Low back pain often improves in 4 weeks or less. In some cases, it may take 12 weeks or more for low back pain to improve. For many people, low back pain improves without specific treatment.

The tables below list some treatments for acute low back pain (lasts for 4 weeks or less) and subacute low back pain (lasts between 4 weeks and 12 weeks). The tables also list what researchers have found about how well the treatments work to reduce pain. For some (but not all) of the treatments, there is also research on how well the treatments help you return to your daily activities.

The tables that follow list some treatments for chronic low back pain (lasts for more than 12 weeks). The tables also list what researchers have found about how well the treatments work to reduce pain. For some (but not all) of the treatments, there is also research on how well the treatments help you return to your daily activities.

What about other treatments that are not listed in this summary?
You may hear about other treatments for low back pain than those listed in this summary. If any low back pain treatment interests you, discuss it with your health care professional.

What are possible side effects of medicines to treat low back pain?

The U.S. Food and Drug Administration (FDA) lists the following possible side effects for medicines to treat low back pain. Just because a side effect is possible does not mean you will have it.

Making a Decision

What should I think about when deciding about treatment?

You and your health care professional can discuss what might be best to treat your low back pain. Here are some things to think about. Be sure to share your thoughts with your health care professional.

• How does your low back pain affect your daily life?
• What are your goals for treatment?
• Which treatment feels like the best fit for you?
• Which possible side effects of treatment concern you?
• How might the cost of treatment affect your decision?
• How much time do you have to spend on treatment?

Ask your health care professional

• Which treatment do you think may be best for me? Why?
• What may help my low back pain in the short term?
• What may help my low back pain in the long term?
• Might medicine help my low back pain? If so, which one?
• What side effects should I watch for? When should I tell you about them?
• Might nonmedicine treatments help my low back pain?
• How long might it take for the treatment to start working?
• Is there anything else I can try?

Low-back pain is a very common condition, but often the cause is unknown. Most people have significant acute back pain at least once in their lives. Usually it resolves on its own without specific treatment.

But for some people, the pain can become chronic or even debilitating, and difficult to treat. Spinal manipulation, acupuncture, massage and yoga are complementary health approaches often used by people with low-back pain. They are all included in a longer list of treatment options recommended by the American Pain Society and the American College of Physicians for patients whose low-back pain does not improve with more conservative care. Other options include exercise, physical/occupational rehabilitation, cognitive-behavioral therapy, and progressive relaxation.

Here’s what you need to know about what the science says for chronic low-back pain and some of thesepractices.

1. Overall, studies have provided good evidence that spinal manipulation is moderately effective for chronic low-back pain.Spinal manipulation includes various interventions administered by osteopathic physicians, chiropractors, and physical therapists.
2. There is fair evidence that acupuncture is helpful in relieving chronic back pain.Current evidence suggests that factors such as expectations and beliefs of the patient and the provider, rather than acupuncture-specific effects of needling, are primarily responsible for beneficial effects of acupuncture on pain.
3. There is also fair evidence that massage is helpful in relieving chronic low back pain.In general, however, these effects appear to be short term.
4. Current research, while limited in scope, suggests that a carefully adapted set of yoga poses may reduce low-back pain and improve function.NCCIH is also supporting research specifically associated with safety of this widely-used self-care practice. People with back pain should work with an experienced teacher who can help modify or avoid some yoga poses to prevent adverse effects.
5. Be sure to tell your health care provider about any complementary health practice you are considering.This will help ensure coordinated, safe care.

What is spinal manipulation?

• Spinal manipulation is also called spinal manipulative therapy. It’s a technique where practitioners use their hands or a device to apply a controlled thrust (that is, a force of a specific magnitude or degree in a specific direction) to a joint of your spine. The amount of force can vary, but the thrust moves the joint more than it would on its own. Spinal manipulation is different from spinal mobilization, which doesn’t involve a thrust (and is performed within a joint’s natural range of motion and can be controlled by the patient).
• Most spinal manipulations are done by chiropractors (chiropractic treatment often involves spinal manipulation), although other licensed professionals including osteopathic physicians and physical therapists also do spinal manipulations.
• Spinal manipulation is one of the most common complementary health approaches used by adults and children in the United States, the 2012 National Health Interview Survey (NHIS) showed.

Why do people use spinal manipulation?

Among U.S. adults who used chiropractic or osteopathic manipulation, about 67 percent used it to treat a specific health condition, and 53 percent used it for wellness, the 2012 NHIS found. Specifically:

• 43 percent used it for general wellness or disease prevention
• 25 percent used it because it focuses on the whole person—their mind, body, and spirit
• 16 percent used it for improved energy
• 11 percent used it for better immune function
• 5 percent used it to improve memory or concentration.

Previous research found that people report positive experiences and reduced pain as a result of receiving spinal manipulation, the NHIS authors noted.

Who uses spinal manipulation and has usage changed?

Between 2012 and 2017, U.S. adults’ use of chiropractic care (which usually involves spinal manipulation) during the past year increased slightly, from 9.1 percent to 10.3 percent, a comparison of NHIS data from the two years showed. The data also show that women were more likely than men to see a chiropractor, and that adults between the ages of 45 and 64 were more likely than people aged 18-44 or 65 and over to have visited one during the past year. According to the same national survey (by the Centers for Disease Control and Prevention’s National Center for Health Statistics), non-Hispanic white adults were much more likely to visit a chiropractor (12.7 percent) than Hispanic (6.6 percent) or non-Hispanic black (5.5 percent) adults.

Among children, there was no significant difference in the use of chiropractic care between 2012 and 2017 (3.5 percent versus 3.4 percent). Older children (age 12 to 17) were more likely than younger ones (age 4 to 11) to have seen a chiropractor, but there was no significant difference in the use of chiropractic care between girls and boys. Non-Hispanic white children were more likely than non-Hispanic black or Hispanic children to have seen a chiropractor.

What are some of the pain conditions for which spinal manipulation has been used?

For Sciatica

• Sciatica is pain associated with the sciatic nerve, which controls muscles in the back of the knee and the lower leg; it also provides feeling to the back of the thigh, part of the lower leg, and the sole of the foot.
• Manipulation isn’t widely used to treat sciatica but it may help, a 2015 research review of a variety of sciatica treatments suggests. However, the studies had many limitations, the authors noted.
• In a 2014 study of 192 people with leg pain associated with back pain, participants who received spinal manipulation, personal instruction, and exercises had less pain after 12 weeks and used less medication a year later than participants who received only personal instruction and exercises. However, leg pain was the same for both groups after 1 year.

For Low-Back Pain

Many noninvasive treatments are available for low-back pain, and these include drugs and nondrug options. In its 2017 clinical guidelines, the American College of Physicians (ACP) suggests that spinal manipulation is one of a number of therapeutic options that may help people with acute or chronic low-back pain (although the ACP says the quality of the evidence is low).

• Spinal manipulation was better than placebo for immediate, short-term relief from acute or subacute low-back and neck pain, a 2010 research review concluded. Manipulation was also better than acupuncture for chronic low-back pain. However, the results of studies comparing spinal manipulation to massage, medication, or physical therapy were mixed.
• A 2011 review of 26 studies concluded that for chronic low-back pain, spinal manipulation works as well as other commonly recommended approaches, including exercise or physical therapy. However, the effect on pain was minimal.
• Twelve sessions of spinal manipulation may be the best “dose,” according to a 2014 NCCIH-funded study of 400 people with chronic low-back pain.
• In a 2014 study of 110 participants with chronic low-back pain, those who received spinal manipulation had less sensitivity to painful stimuli right after getting spinal manipulation, compared to people who got sham spinal manipulation. But after a couple of weeks the two groups had similar amounts of pain and disability, the study showed. The study was supported by NCCIH.
• The Agency for Healthcare Research and Quality (AHRQ) systematic review of noninvasive nonpharmacologic treatment for chronic pain reported that spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in the short term (i.e., 1-6 months following treatment) and intermediate term (i.e., 6-12 months). The report concluded the strength of the evidence was low. In addition, the report concluded that there was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain, but manipulation was associated with slightly greater effects than controls on intermediate-term pain. The standard of evidence was considered low for short-term effects and moderate for intermediate-term effects.
• The research on spinal manipulation for acute low-back pain is generally mixed and has many limitations.
  • Spinal manipulation is no more effective for acute low-back pain than sham (fake) spinal manipulation, or when added to another treatment such as standard medical care, a 2012 research review of 20 studies found. Spinal manipulation appeared to be safe when compared to other treatment options.
  • In a 2015 study of 220 people with acute low-back pain, participants who received physical therapy, which included spinal manipulation, fared no better than those who received standard care.
  • However, a 2015 NCCIH-funded study of 107 adults with recent-onset acute and subacute low-back pain found that those receiving spinal manipulation got greater short-term relief, compared to participants getting standard medical care. Furthermore, the study compared two different techniques—manual thrust manipulation (MTM) and mechanical assisted manipulation (MAM)—and found MTM led to greater short-term reductions in self-reported pain and disability than MAM or usual care.
  • A 2017 analysis examined data from 15 randomized controlled trials with almost 1,700 participants. The researchers concluded that spinal manipulative therapy can modestly improve pain and function in people with acute low-back pain.
• Results of a 2018 study with 750 active duty U.S. military personnel with low-back pain found that those who received chiropractic care in addition to usual care had better short-term improvements in low-back pain intensity and pain-related disability than those who only received usual medical care.

For Neck Pain

• For patients with acute neck pain, either spinal manipulation or home exercises appeared to be more effective than medication in the short and long term, an NCCIH-funded study of 272 patients showed in 2012. A 2015 research review that looked at results from 51 trials with 2,920 participants also reported that there’s weak evidence that spinal manipulation may provide short-term relief from acute or chronic neck pain.

For Headache

• For preventing migraines, spinal manipulation may be one of several complementary health approaches (including massage therapy) that’s as helpful as medications used for migraine prevention, but the research isn’t conclusive.
• The AHRQ systematic review of noninvasive nonpharmacologic treatment for chronic pain reported spinal manipulation therapy was associated with slight to moderate improvements in function compared to usual care on the Headache Impact Test and the Headache Disability Inventory (scale 0-100) and in pain over the short term (i.e., 1-6 months) in one trial. The standard of evidence was rated as low.

For Other Conditions

• Researchers have studied spinal manipulation for many other conditions, including fibromyalgia, children’s ear infections, chronic obstructive pulmonary disease (COPD), infant colic, and bedwetting, but there’s too little evidence to know if it helps with these problems.
• Spinal manipulation doesn’t help with asthma, hypertension, or menstrual pain, studies show.

Is spinal manipulation safe?

Spinal manipulation is relatively safe when performed by a trained and licensed practitioner. The most common side effects of spinal manipulation are temporary muscle soreness, stiffness, or a temporary increase in pain.

Serious complications, deaths, and delays in diagnosis of serious illnesses have been associated with spinal manipulation, including in children, but are very rare.

Strokes and Artery Tears

• A type of spinal manipulation that focuses on the neck has been linked to small, potentially dangerous tears in the artery walls in the neck, called cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.

Spinal Manipulation and Pregnancy

• There are few reports of spinal manipulation causing problems during pregnancy or in the period after childbirth, a 2012 research review reported. The problems that have been reported ranged from mild, temporary pain to life-threatening injuries. Serious adverse events occurred only after cervical spinal manipulation.

NCCIH-Funded Research

NCCIH-supported studies have been investigating:

• The clinical impact spinal manipulation/chiropractic may have on chronic low-back pain in U.S. veterans
• How spinal manipulation compares with prescription drug therapy for long-term management of chronic low-back pain in older adults
• How to optimize spinal manipulation treatment protocols for patients with low-back pain
• Patients’ experiences and satisfaction with chiropractic care for chronic neck pain
• How to best provide chiropractic care for veterans with musculoskeletal pain and mental health disorders.

More to Consider

• In a 2017 clinical practice guideline, the ACP suggested that spinal manipulation remains a recommended treatment option for chronic low-back pain, saying that it is one of several options that show some evidence of effectiveness.
• Before selecting a chiropractor:
  • Ask about the chiropractor’s education and licensure.
  • Tell the chiropractor about all of your medical conditions.
  • Ask if the chiropractor has specialized training or experience treating your condition.
  • Ask about how many sessions you’ll need and typical out-of-pocket costs and insurance coverage. (Medicare Part B covers manual manipulation of the spine if it is determined to be medically necessary.)
  • Tell the chiropractor about any medications (prescription or over-the-counter) and dietary supplements you take. If the chiropractor suggests a dietary supplement, ask about potential interactions with your medications or other supplements.
• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Recurring back pain resulting from improper body mechanics may be prevented by avoiding movements that jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture.

Recommendations for keeping one’s back healthy

• Exercise regularly to keep muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
• Maintain a healthy weight and eat a nutritious diet with sufficient daily intake of calcium, phosphorus, and vitamin D to promote new bone growth.
• Use ergonomically designed furniture and equipment at home and at work. Make sure work surfaces are at a comfortable height.
• Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. Put your feet on a low stool or a stack of books when sitting for a long time.
• Wear comfortable, low-heeled shoes.
• Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
• Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
• Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.