Managing Chronic Back Pain: Treatment Options

Clinical guidance from bodies including the American College of Physicians has moved decisively toward non-pharmacological first-line treatment for both acute and chronic low back pain.

Imaging usually does not help early on

For non-specific low back pain without red flag features, guidelines generally advise against routine imaging in the first several weeks. The reason is that imaging findings correlate poorly with pain.

Studies of asymptomatic people have repeatedly found high rates of disc degeneration, bulges and other findings in individuals with no pain at all, with prevalence rising steadily with age. Finding such changes on a scan therefore does not establish them as the cause, and being told you have degeneration can itself increase fear and reduce activity.

Red flags that do warrant prompt assessment include significant trauma, unexplained weight loss, fever, history of cancer, progressive neurological deficit, and bladder or bowel dysfunction with saddle numbness — the last being a medical emergency.

Movement rather than rest

Prolonged bed rest was standard advice decades ago and is now specifically discouraged, because it is associated with slower recovery. Remaining active within tolerance is recommended.

Exercise therapy has among the best evidence for chronic low back pain. No single modality has proven clearly superior — motor control exercise, general strengthening, Pilates-based programmes, aerobic exercise and yoga all show benefit. Adherence appears to matter more than the specific programme, which suggests choosing something you will continue.

Physiotherapy provides supervised progression and technique correction, which is particularly valuable early or after a flare.

Psychological factors are not a suggestion that pain is imaginary

Persistent pain involves changes in how the nervous system processes signals, and psychological factors influence that processing. Fear of movement, catastrophising and low mood are associated with worse outcomes.

This does not mean the pain is not real. It means treatments addressing these factors work. Cognitive behavioural therapy, acceptance and commitment therapy, and mindfulness-based stress reduction all have supporting evidence for chronic low back pain, generally with modest but genuine effect sizes.

Pain neuroscience education — explaining how persistent pain works — has been shown to reduce fear and improve function when combined with exercise.

Medication, in proportion

NSAIDs are generally first-line pharmacological treatment, with the caveat of gastrointestinal, renal and cardiovascular risks, particularly with prolonged use or in older adults.

Paracetamol has performed poorly for low back pain specifically in trials. Muscle relaxants may help short-term in acute episodes and cause sedation. Certain antidepressants, notably duloxetine, have evidence in chronic pain.

Opioids are no longer recommended as routine treatment for chronic low back pain. Guidelines have narrowed their role substantially given limited long-term benefit and significant risks including dependence.

Injections and surgery

Epidural steroid injections may give short-term relief for radicular pain from nerve root compression, with limited evidence of long-term benefit and little support for non-radicular back pain.

Surgery has clearer indications in specific circumstances: persistent radiculopathy with corresponding imaging findings that has not responded to conservative care, spinal stenosis with significant functional limitation, and progressive neurological deficit. Fusion for non-specific back pain without these features has weaker supporting evidence and is more contested.

Second opinions before elective spinal surgery are reasonable and commonly encouraged.

A practical approach

Stay active, resume normal activity as tolerated, and build a regular exercise habit that you will maintain. Address sleep and stress, both of which amplify pain. Avoid prolonged rest and avoid interpreting normal age-related imaging findings as damage.

Set function-based goals rather than pain-elimination goals — walking a certain distance, returning to a specific activity. Improvement in function often precedes reduction in pain.