Low Back Pain

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
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This topic provides a general overview of low back pain. If you have been diagnosed with a herniated disc or spinal stenosis, see the topic Herniated Disc or Lumbar Spinal Stenosis.

What is low back pain?

Low back pain can affect the back anywhere below the ribs and above the legs. The lower back is the connection between the upper and lower body, and it bears most of the body’s weight. Because of these roles, it is easily injured when you lift, reach, or twist.

Almost everyone has low back pain at one time or another. The good news is that most low back pain will go away in a few weeks with some basic self-care. But if your pain is severe or lasts more than a couple of weeks, see your doctor.

What causes low back pain?

Low back pain is often caused by overuse, strain, or injury. For instance, people often hurt their backs playing sports or working in the yard, being jolted in a car accident, or lifting something too heavy.

Aging plays a part too. Your bones and muscles tend to lose strength as you age, which increases your risk of injury. The spongy discs between the bones of the spine (vertebrae) may suffer from wear and tear and no longer provide enough cushion between the bones. A disc that bulges or breaks open (herniated disc) can press on nerves, causing back pain.

In some people, low back pain is the result of arthritis, broken vertebrae (compression fractures) caused by bone loss (osteoporosis), illness, or a spine problem you were born with.

Often doctors don't really know what causes low back pain. But it is more likely to become long-lasting (chronic) if you are under stress or depressed.

What are the symptoms?

Depending on the cause, low back pain can cause a range of symptoms. It may:

• Be dull, burning, or sharp.
• Be felt at a single point or over a broad area.
• Come on gradually or suddenly.
• Occur with muscle spasms or stiffness.
• Cause leg symptoms, such as pain, numbness, or tingling, often extending below the knee. These symptoms can occur on their own or along with low back pain. Leg symptoms are often caused by lower spine problems that place pressure on a nerve that leads to the leg.

A rare but serious problem called cauda equina syndrome can occur if the nerves at the end of the spinal cord are squeezed. Seek emergency treatment if you have weakness or numbness in both legs, or loss of bladder or bowel control.

Doctors say back pain is:

• Acute if a spell (or episode) of pain lasts less than 3 months. Most back pain is acute and goes away with 4 to 6 weeks of home treatment.
• Recurrent if acute symptoms come back. Most people have at least one episode of recurrent low back pain.
• Chronic if your back bothers you most of the time for longer than 3 months.

How is low back pain diagnosed?

The doctor will ask questions about your past health, symptoms, and work and physical activities. He or she will also do a physical exam. Your answers and the exam can help the doctor rule out a serious cause for the pain. In most cases, doctors are able to recommend treatment after the first exam.

Most people do not need further testing. Imaging tests such as X-rays, CT scans, and MRIs are not helpful for diagnosing most episodes of low back pain. In most cases, they are only used if the doctor suspects a serious problem, such as a herniated disc, a broken bone, or cancer, or if surgery is being considered or planned. You might also have imaging tests if worker’s compensation or a lawsuit is involved.

How is it treated?

Most low back pain will improve with the following treatment:

• For the first day or two, rest in a comfortable position. Try lying on your side with a pillow between your knees. Or lie on your back on the floor with a pillow under your knees. Do not stay in one position for too long, though. Every 2 to 3 hours, take a short walk (about 10 to 20 minutes), then rest in a comfortable position again.
• Take over-the-counter pain medicine if needed, such as acetaminophen (Tylenol, for example) or an anti-inflammatory drug such as aspirin or ibuprofen (Advil or Motrin, for example). These medicines usually work best if you take them on a regular schedule instead of waiting until the pain is severe.
• Try using a heating pad on a low or medium setting, or a warm shower, for 15 to 20 minutes every 2 or 3 hours. You can also buy single-use heat wraps that last up to 8 hours. You can also try an ice pack for 10 to 15 minutes every 2 to 3 hours. There is not strong evidence that either heat or ice will help, but you can try them to see if they help.
• As soon as possible, get back to your normal activities. Staying in bed for more than 1 or 2 days can weaken your muscles and make the problem worse.

Walking is the simplest and maybe the best exercise for the lower back. It gets your blood moving and helps your muscles stay strong. Start with easy walks of 5 to 10 minutes a day, and gradually increase your time. Walking in water up to your waist or chest is also good exercise.

A doctor or physical therapist can recommend more specific exercises to help your back muscles get stronger. These may include a series of simple exercises called core stabilization. The muscles of your trunk, or core, support your spine. Strengthening these muscles can improve your posture, keep your body in better balance, and lower your chance of injury.

Some people get relief from pain by using treatments such as massage, spinal manipulation (chiropractic or osteopathic manipulation), or acupuncture. Certain treatments work for some people but not for others. You may need to try different things to see which work best for you.

If your symptoms are severe or you still have them after 2 weeks of self-care, see your doctor. You may need stronger pain medicines, or you might benefit from physical therapy.

Having ongoing back pain can make you depressed. In turn, depression can have an effect on your level of pain and whether your back gets better. People with depression and chronic pain often benefit from both counseling and medicine. A cognitive-behavioral therapist can teach stress management and pain control skills. Antidepressant medicines may help too.

Only a few people with low back pain need surgery. Surgery may help if you have a herniated disc or back pain along with symptoms of nerve damage, such as numbness in your legs. Even in these cases, most people will improve without surgery. Having surgery does not guarantee that all your pain will go away. Before you have surgery, it is a good idea to get a second opinion.

How can you prevent low back pain from returning?

After the first time you have had low back pain, you are likely to have it again. To help keep your back healthy and avoid further pain:

• Practice good posture when you sit, stand, and walk.
• Get regular, low-impact exercise. Walk, swim, or ride a stationary bike. Stretch before you exercise.
• Wear low-heeled shoes with good support.
• Sleep on your side. A medium-firm mattress may put the least stress on your back.
• Watch your weight. Being too heavy, especially around your waist, puts extra stress on your back.
• Don't try to lift things that are too heavy for you. When you must lift, bend your knees and keep your back straight, keep the object you are lifting close to your belly button, and avoid lifting and twisting at the same time. See a picture of proper lifting technique.

If you sit or stand for long periods at work:

• Pay attention to your posture. Sit or stand up straight, with your shoulders back.
• Make sure your chair has good back support.
• Take regular breaks to walk around.

If your work involves a lot of bending, reaching, or lifting:

• Talk to your human resources department to see if there are other ways you can do your work.
• Don't depend on a “back belt” to protect your back. Studies have not shown these belts to be effective in reducing back injuries. The most they can do is to help remind you to use good techniques for lifting.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have magnetic resonance imaging (MRI) for low back pain?
	Should I have spinal manipulative therapy for low back pain?
	Should I have surgery for a herniated disc?
	Actionsets are designed to help people take an active role in managing a health condition.
	Back problems: Proper lifting
	Fitness: Increasing core stability
	Low back pain: Exercises to reduce pain

Most low back pain is triggered by some combination of overuse, muscle strain, and injury to the muscles, ligaments, and discs that support the spine. Many experts believe that over time muscle strain can lead to an overall imbalance in the spinal structure. This leads to a constant tension on the muscles, ligaments, bones, and discs, making the back more prone to injury or reinjury.

The causes of pain in the low back, or lumbosacral region, tend to add on to one another. For example, after straining muscles, you are likely to walk or move in different ways to avoid pain or to use muscles that aren't sore. That can cause you to strain other muscles that don't usually move that way.

The most common causes of low back pain are:

• Injury or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.
• Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by:
  • A herniated disc, often brought on by repeated vibration or motion (as during machine use or sport activity, or when lifting improperly), or by a sudden heavy strain or increased pressure to the lower back.
  • Osteoarthritis (joint degeneration), which typically develops with age. When osteoarthritis affects the small facet joints in the spine, it can lead to back pain. Osteoarthritis in other joints, such as the hips, can cause you to limp or to change the way you walk. This can also lead to back pain.
  • Spondylolysis and spondylolisthesis, vertebra defects that can allow a vertebra to slide over another when aggravated by certain activities.
  • Spinal stenosis, or narrowing of the spinal canal, which typically develops with age.
  • Fractures of the vertebrae caused by significant force, such as from an auto or bicycle accident, a direct blow to the spine, or compressing the spine by falling onto the buttocks or head.
  • Spinal deformities, including curvature problems such as severe scoliosis or kyphosis.
• Compression fractures. Compression fractures are more common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid use. In a person with osteoporosis, even a small amount of force put on the spine, as from a sneeze, may cause a compression fracture.

Less common spinal conditions that can cause low back pain include:

• Ankylosing spondylitis, which is a form of joint inflammation (arthritis) that most often affects the spine.
• Bacterial infection. Bacteria are usually carried to the spine through the bloodstream from an infection somewhere else in the body or from IV drug use. But bacteria can enter the spine directly during surgery or injection treatments, or as the result of injury. Back pain may be the result of an infection in the bone (osteomyelitis), in the spinal discs, or in the spinal cord.
• Spinal tumors, or growths that develop on the bones and ligaments of the spine, on the spinal cord, or on nerve roots.
• Paget's disease, which causes abnormal bone growth most often affecting the pelvis, spine, skull, chest, and legs.
• Scheuermann's disease, in which one or more of the bones of the spine (vertebrae) develop wedge-shaped deformities. This causes curvature of the spine (rounding of the back, or kyphosis), most commonly in the chest region.

Other medical conditions that can cause pain that may be similar to low back pain include:

• Pelvic inflammatory disease.
• Aortic aneurysm.
• Peptic ulcers.
• Gallbladder disease.
• Pancreatitis.
• Urinary disorders such as kidney stones or urinary tract infections.
• Prostate disease.

Your state of mind also has an effect on your level of pain and whether it becomes long-lasting (chronic). People who are depressed, under stress, unhappy in their work, or seeking money for an injury are more likely to have chronic back pain.

The type, location, and severity of low back pain depends upon what is causing it.

Symptoms of a back sprain or strain generally include:

• Muscle spasms, cramping, and stiffness.
• Pain, mostly in the back and buttocks. The pain may develop quickly or over a longer period of time. Pain generally occurs in episodes. It is aggravated by weight-bearing or specific movements and is relieved by rest. The most severe pain usually lasts 48 to 72 hours and may be followed by days or weeks of less severe pain. The back is easily reinjured during this time.

Symptoms of nerve-root pressure generally include:

• Leg pain. If pain extends below the knee, it is more likely to be due to pressure on a nerve than to a muscle problem. Most commonly, the pain starts in the buttock and travels down the back of the leg as far as the ankle or foot. This pain pattern is known as sciatica.
  • Pain may come on suddenly or gradually. It may vary from mild to severe, and it can be constant or it may come and go. It is usually sharp and burning and is made worse by sneezing, coughing, or straining to pass stools. Some people describe it as a shooting pain. The pain usually affects only one leg.
  • Depending on the cause of your low back pain, symptoms may be better or worse in various positions, such as bending forward (flexion) or backwards (extension). If bending forward increases symptoms, walking, lying down, and movements that straighten (extend) the spine usually relieve symptoms. The opposite is also true: if your symptoms are worse when you stand or walk, they are usually relieved by sitting down or lying down on your back with your knees bent, and by gentle exercises to bend your spine forward (flex).
  • Pain can also be made worse by activities that cause you to forcefully contract the core muscles of your trunk, such as a cough, sneeze, or a difficult bowel movement, or if you hold your breath during an activity (Valsalva maneuver).
• Nerve-related problems, such as tingling, numbness, or weakness in one leg or in the foot, lower leg, or both legs. Tingling may begin in the buttock and extend to the ankle or foot. Weakness or numbness in both legs, or loss of bladder and/or bowel control, are symptoms of cauda equina syndrome, which requires immediate medical attention.

Symptoms of arthritis of the spine generally include pain and stiffness that are worse in the back and hip region. Arthritis pain starts gradually, gets worse over time, and lasts longer than 3 to 6 months. It is generally worse in the morning or after prolonged periods of inactivity. Arthritis pain gets better when you move around. Symptoms caused by arthritis and symptoms due to back injury are often similar and commonly occur together.

Symptoms of diseases that affect the spine vary depending upon the type of illness. They may include:

• Pain that is worse in the affected part of the spine (for instance, if there is a compression fracture, tumor, or infection).
• Pain that starts gradually, is constant, and may be sharp or a dull ache. Bed rest does not make it better and may make it worse (tumors on the spine often cause night pain). The pain lasts longer than 2 to 3 weeks.
• Fever.
• Sensitivity of the spine to touch and pressure.
• Pain that wakes you up from sleep.

Other symptoms or conditions that may occur with low back pain and require additional evaluation and treatment include:

• Depression.
• Drug or alcohol abuse. Use of intravenous (injected or IV) illegal drugs is especially risky.
• Use of steroids over a long period of time.
• Unexplained weight loss.
• Fever.
• A history of cancer.
• Bladder or bowel problems.
• An illness or condition that affects the immune system, such as diabetes, chemotherapy for cancer treatment, HIV (AIDS), or an organ transplant.

The course of low back pain depends both on its cause and on how well you treat your back.

• Most low back pain lasts less than 3 months. Overall, 60% of low back pain goes away within 1 week, 90% within 6 weeks, and up to 95% recover within 12 weeks. Over 98% of low back pain is gone within 1 year.¹
• After the first time you have hurt your back, you are more likely to hurt your back again. Many people who recover from low back pain will have a repeat episode within a year. Most people will have it again sometime during their lives.
• Long-lasting (chronic) pain not only makes you tired, irritable, and less productive and active, but it can trigger other problems. If your back pain causes you to use your body in different ways (for example to limp or to sit differently), pain can develop in other areas of the body. Pain can also cause biochemical changes in your body that tend to keep the pain going. Without specialized treatment, chronic pain syndrome can become disabling.

Low back pain is often triggered by some combination of overuse, muscle strain, or injury to the muscles and ligaments that support the spine. Less commonly, low back pain is caused by illness or spinal deformity.

A risk factor is something that increases your chances of having back pain. More risk factors means you have a higher chance of having back pain.

Risk factors that you cannot change include:

• Being middle-aged (risk drops after age 65).
• Being male.
• Having a family history of back pain.
• Having had a previous back injury.
• Being pregnant. A woman's back is significantly stressed by carrying a baby.
• Having had compression fractures of the spine.
• Having had previous back surgery.
• Having spine problems since birth (congenital spine problems).

Risk factors that you can change with lifestyle changes or medical treatment include:

• Not getting regular exercise.
• Doing a job or other activity that requires long periods of sitting, lifting heavy objects, bending or twisting, repetitive motions, or constant vibration, such as using a jackhammer or driving certain types of heavy equipment.
• Smoking. Smokers are more likely than nonsmokers to have low back pain.
• Being overweight. Excess body weight, especially around the waist, may put strain on your back, although this has not been proven. But being overweight often also means being in poor physical condition, with weaker muscles and less flexibility. These can lead to low back pain.
• Having poor posture. Slumping or slouching alone may not cause low back pain, but after the back has been strained or injured, bad posture can make pain worse.
• Being under stress. Stress and other emotional factors are believed to play a major role in low back pain, particularly chronic low back pain. Many people unconsciously tighten their back muscles when they are under stress.
• Having long periods of depression.
• Using medicines long-term that weaken bones, such as corticosteroids.

Give your low back pain a day or two to work itself out before you call your doctor, unless you have signs of a severe illness, injury, or heart attack, as described below.

Call 911 or other emergency services immediately if:

• You have back pain with chest pain. Always call 911 any time you think you might have symptoms of a heart attack. Symptoms of a heart attack can include:
  • Pain in the upper back with chest pain or discomfort that is crushing or squeezing or feels like a heavy weight on the chest.
  • Chest discomfort or pain that occurs with:
    • Sweating.
    • Shortness of breath.
    • Nausea or vomiting.
    • Pain that spreads from the chest to the back, neck, or jaw, upper belly, or one or both shoulders or arms. The left shoulder and arm are more commonly affected. See a picture of areas that may be affected by chest pain.
    • Dizziness, lightheadedness, or feeling like you are going to faint.
    • A fast, slow, or irregular heartbeat.
• You had a severe injury to your back. Signs of spinal injury include:
  • New loss of bowel or bladder control.
  • New weakness in the legs.
  • New numbness or tingling in the buttocks, genital area, or legs.
  • Moderate to severe pain following an injury to the back.

Note: If you suspect that someone has a spinal injury, don't move the person except to avoid an immediate threat, such as a fire. If there is immediate danger, keep the head, neck, and back supported and aligned while you move the person to safety.

For more information, see the topic Back Problems and Injuries.

Watchful Waiting

Most low back pain does not require a visit to a doctor. In general, pain should start to improve after 1 or 2 days of home treatment.

If you have pain that has not improved after 1 or 2 days and you are unable to do your normal daily activities, call your doctor.

If your mild to moderate low back pain has continued through at least 2 weeks of home treatment, talk with your doctor. He or she may want to check for problems that may be causing your back pain.

Who To See

The following health professionals can diagnose the cause of back pain, evaluate back injuries, and start treatment:

• Primary care provider such as:
  • Family medicine doctor
  • Internist
  • Nurse practitioner
  • Physician assistant
• Orthopedic surgeon
• Osteopathic doctor (osteopath)
• Emergency medicine specialist
• Chiropractor

You may also be referred to one of the following specialists for treatment:

• Physical therapist
• Physiatrist
• Cognitive-behavioral therapist
• Neurosurgeon
• Orthopedic surgeon
• Rheumatologist
• Pain management specialist if low back pain has lasted for more than 3 months

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Initial exam for low back pain

Your doctor will begin by asking questions about your medical history, your symptoms, and your work and physical activities. He or she will also do a physical exam. The questions and exam can help him or her rule out a serious cause for your pain. Your doctor may also ask questions about stress at home and at work that may make you more susceptible to chronic pain.

For most people with low back pain, the doctor will be able to recommend treatment after the initial exam. Your doctor will probably recommend that you begin home treatment and possibly physical therapy.

If you are older than 50 or you have symptoms of a specific illness, your doctor may recommend more tests.

Tests for low back pain

If your initial exam shows no signs of a serious condition, you will probably not need to have an imaging test. Imaging tests are typically done if:

• You are over 50 years of age.
• You have had spine problems since birth (congenital spine problems).
• The history and physical exam reveal signs of a serious problem, such as a fracture, tumor, infection, or severe nerve damage.
• You have a history of any type of arthritis in your spine.
• You have a history of a previous spine injury or back surgery.
• You have a history of long-term steroid use or a history of drug abuse.
• Back pain has not improved after at least 4 weeks of home treatment that may include pain relievers, heat or ice, and exercises.
• Your symptoms are worse.
• You have had several episodes of severe pain.
• You and your doctor are considering surgery.
• Workers' compensation is involved because you had an injury on the job.
• You are involved in a lawsuit concerning your injury.

The type of imaging test will depend on what kind of problem your doctor suspects. You may have one or more tests, such as:

• Spinal X-ray.
• MRI.
• CT scan.
• Bone scan.

For more information about MRI for low back pain, see:

Should I have an MRI for low back pain?

Imaging tests such as the myelogram and discography have been largely replaced by simpler and more effective methods for basic testing. They are sometimes still used in hard-to-diagnose cases or before surgery. If your doctor recommends discography, experts recommend getting a second opinion before having the test.

If you have leg pain or numbness, you may have an electromyogram and nerve conduction studies to find out how severely your nerve function is being affected. Electromyogram and nerve conduction studies check the function of the spinal cord, nerve roots, and nerves and muscles that control your arms and legs.

Blood tests are sometimes used to look for a metabolic disorder, arthritis, cancer, or an infection. Bone scans may also be used to look for cancer or infection.

A wide range of treatment is available for low back pain, depending on what is causing the pain and how long it lasts. Most people find that their low back pain improves within a few weeks. Chances are good that your pain will go away soon with some basic self-care.

As you consider treatment for your low back pain, keep the following in mind:

• If you have recently developed low back pain, stay active and consider taking over-the-counter pain medicines such as acetaminophen (Tylenol, for example) or nonsteroidal anti-inflammatory drugs (NSAIDs). Examples of NSAIDs are ibuprofen (Advil or Motrin) and naproxen (Aleve or Naprosyn). Staying active is better for you than bed rest. In fact, staying in bed more than 1 or 2 days can actually make your pain worse and lead to other problems such as stiff joints and muscle weakness.²
• Research shows that people who understand their low back pain are more satisfied.³ Be sure to ask your doctor or physical therapist if you have questions about your symptoms, how to manage your back pain, or activities you can do or should not do.
• If your low back pain has lasted longer than 3 months, you will probably benefit from more intensive treatment. Programs that combine strengthening exercises with education and activities to help you increase your function and manage your pain are often effective.⁴
• Surgery is rarely needed for low back pain. Even if you have a herniated disc or nerve damage, you are likely to improve without surgery.
• After you have had low back pain once, the pain is likely to come back. To avoid further problems, keep your back and stomach muscles strong, use good posture, learn the safest way to lift heavy objects, and learn to manage stress.

Treatment for acute low back pain

Acute low back pain is pain that has lasted less than 3 months. If you have recently started to have low back pain, there's a good chance that it will get better within a few weeks. Most low back pain will improve if you take the following steps:

• For the first day or two, rest in a comfortable position. Try lying on your side with a pillow between your knees. Or lie on your back on the floor with a pillow under your knees. Do not stay in one position for too long, though. Every 2 or 3 hours, take a short walk (about 10 to 20 minutes), then find a comfortable position to rest again.
• Take pain medicine if needed, such as acetaminophen (Tylenol) or medicines that reduce pain, swelling, and irritation, including ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve or Naprosyn). These medicines usually work best if you take them on a regular schedule instead of waiting until the pain is severe.
• Try using a heating pad on a low or medium setting, or a warm shower, for 15 to 20 minutes every 2 to 3 hours. Or you can buy single-use heat wraps that last up to 8 hours. You can also try an ice pack for 10 to 15 minutes every 2 to 3 hours. There is not strong evidence that either heat or ice will help, but you can try them to see if they help. You may also want to try switching between heat and cold.
• As soon as possible, get back to your normal activities. Movement helps your muscles stay strong. Staying in bed for more than 1 or 2 days can actually make your problem worse.

Walking is the simplest and perhaps the best exercise for the low back. Your doctor or a physical therapist can recommend more specific exercises to help your back muscles get stronger. These may include a series of simple exercises called core stabilization. The muscles of your trunk, or core, support your spine. Strengthening these muscles can improve your posture, keep your body in better balance, and decrease your chance of injury. For more information, see:

Fitness: Increasing core stability.

Most people have at least one repeat episode of low back pain. If you have had low back pain, remember that your back is now more vulnerable than before. Keep your stomach and back muscles strong, lift properly, and use good posture. For more information, see:

Low back pain: Exercises to reduce pain.

Back problems: Proper lifting.

One treatment choice for acute low back pain is spinal manipulation, or spinal manual therapy. The aim of spinal manipulation is to increase a joint's range of motion. Spinal manipulation can be done by a chiropractor, osteopathic doctor, and some physical therapists or physiatrists. For more information on this type of treatment, see:

Should I have spinal manipulative therapy to treat low back pain?

New research suggests that a brief program of instruction in pain management—addressing how to manage usual daily activities, how to deal with worries about back pain, and overcoming fear of causing pain—can also be an effective treatment for low back pain.⁵

Treatment for ongoing (chronic) low back pain

Chronic low back pain is pain that has lasted longer than 3 months. As low back pain continues beyond 3 months, it becomes vitally important that you develop skills for managing and coping with chronic pain so you can avoid getting into a cycle of sleeplessness, inactivity, irritability, depression, and more pain.

Chronic pain often requires both psychological counseling and medical treatment, because pain has a wearing effect on both the mind and the body. Seek out a cognitive-behavioral therapist who can teach you stress management and pain control skills. Look for a "back school" program and at least one type of health professional who specializes in spinal care. The most successful programs are usually those that combine exercise, activities to increase your function, and techniques to help you manage pain.⁴ Depending on your condition, you can start taking charge of pain by continuing with home treatment measures and using one or more of the following treatments:

• Daily exercises to strengthen your trunk and back. See a physical therapist for specific exercises. For more information, see:

  Fitness: Increasing core stability. One study suggests that this type of exercise may be more effective than either manual therapy or education as a part of physical therapy for chronic low back pain.⁶

  Low back pain: Exercises to reduce pain.

• Medicines, if needed. They are not effective for all people, but medicines that doctors sometimes suggest for low back pain include:
  • Acetaminophen to reduce pain and/or medicines that reduce pain, swelling, and irritation, including ibuprofen (such as Advil or Motrin) and naproxen (such as Aleve or Naprosyn). These medicines usually work best if you take them on a regular schedule instead of waiting until the pain is severe.
  • Prescription pain medicine or muscle relaxants for a short time, to help break the pain cycle.
  • Antidepressants, to treat chronic pain. This type of medicine not only treats depression but may have an additional effect on chronic pain.
  • Anesthetic or corticosteroid injections, to block pain sensation or reduce inflammation.
• Other therapies. These may include:
  • Heat and/or ice, depending on which seems to help you more. You may want to try switching between heat and cold.
  • Therapeutic massage, to ease muscle spasm.
  • Spine adjustment (manipulation), by an osteopath, chiropractor, physiatrist, or a physical therapy spine specialist. People who benefit from this usually notice improvement after one visit, and additional manipulation may not be needed.⁷
  • Cognitive-behavioral therapy or biofeedback, for controlling pain and pain triggers. See a psychologist, licensed counselor, or clinical social worker who specializes in pain management skills.
  • Acupuncture, which may help decrease pain and increase activity. Some studies show that acupuncture reduced pain and disability related to back problems more than usual treatment.^{8, 9} In contrast, a summary of several studies showed that acupuncture reduced pain and increased the ability to be active, but not any more than other treatments.¹⁰

Several experimental treatments are controversial, with little evidence that they help. These include:

• A traction-like treatment called vertebral axial decompression.
• Percutaneous disc decompression such as intradiscal electrothermic therapy (IDET).
• Radiofrequency ablation for facet joint pain.
• Botulinum (Botox) injection.
• Prolotherapy.

Facet joint injections and spinal traction are not considered to be safe and effective treatments for chronic low back pain.⁴

Treatment if low back pain gets worse or comes back

See your doctor if you have moderate to severe low back pain that lasts more than a couple of days; if you have back or leg symptoms that have gotten worse; if your symptoms have not gone away after 2 weeks of home treatment; or if improved symptoms flare up again. A physical exam and possibly an imaging test may produce new information about your condition and help direct your treatment decisions.

• If no serious cause of mild to moderate low back pain is apparent (as in 85% of cases), your doctor will probably advise you to continue with home treatment.¹¹ Consider seeing a physical therapist for back-healthy exercises to use every day, as long as they don't make your symptoms worse. A medicine to reduce pain, moist heat application, massage, cognitive-behavioral therapy, learning how to best use your back in a "back school" program, chiropractic therapy (also called spinal manipulation), or biofeedback may also help prevent your symptoms from becoming chronic.
• If your pain is severe, your doctor may recommend short-term use of an opiate painkiller, epidural steroid injection, or muscle relaxant. These medicines have potential harms and side effects, but these may be balanced out if the medicines help you. Epidural steroid injections are usually used only for people with symptoms from a herniated disc, such as pain in the buttocks and down into the leg. Talk with your doctor about the expected benefits and side effects of any medicine.
• If your pain is caused by another health problem, such as a herniated disc, spinal stenosis, ankylosing spondylitis, osteoarthritis, cancer, or infection, your doctor will make specific treatment recommendations.

If you have a herniated disc, your doctor may recommend surgery. Most doctors will wait to consider surgery until after you have tried nonsurgical treatment for 1 to 3 months without improvement (but usually before more than 6 months have gone by). Surgery is eventually considered for about 1 out of 10 people who have a herniated disc.¹² For more information, see:

Should I have surgery for a herniated disc?

For more information about specific conditions, see:

• Lumbar Spinal Stenosis.
• Ankylosing Spondylitis.
• Osteoarthritis.
• Herniated Disc.

At one time, traction was a common treatment for low back pain. Traction was thought to stretch the spine and reduce pressure on the spinal discs. Recent research does not prove that traction will reduce acute or chronic low back pain.^{2, 4}

There is no clear evidence that you can prevent low back pain.¹³ Nearly everyone experiences it at some time. But there are some things you can do to help prevent low back pain. And they can prepare you for faster recovery if you do have low back pain. Some of them also have added health benefits. Here are some things you can do:

• Exercise to keep your back healthy and strong. Exercise programs that include aerobic conditioning and strengthening exercises can help reduce the recurrence of low back pain. For more information, see:

  Fitness: Increasing core stability.

  Low back pain: Exercises to reduce pain.

• Learn how to lift objects safely to protect your back. For more information, see:

  Back problems: Proper lifting.

• Protect your back while sitting. Standing posture is also important. When you stand, your ears, shoulders, hips, and knees should be in line with one another.
• Try different sleeping positions that protect your back. If you sleep on your side, try putting a pillow between your knees. If you sleep on your back, use a pillow under your knees. You can also try rolling up a small towel and using it to support your lower back.
• Wear low-heeled shoes.
• Maintain a healthy weight to avoid excess strain on your lower back. For more information, see the topic Healthy Weight.
• If you're a smoker, quit. Smoking increases your risk of bone loss (osteoporosis) and increases your sensitivity to pain. Smoking also interferes with blood circulation by tightening the arteries, which makes it harder for blood to flow, and by decreasing the amount of oxygen the red blood cells can carry. Spinal discs do not have their own blood supply, but receive nutrition in part from the blood supply to the vertebral bones above and below them. Decreased circulation may increase the speed of degeneration and/or slow the healing of the discs. For more information on how to quit, see the topic Quitting Tobacco Use.
• Eat a nutritious diet. Getting plenty of calcium, phosphorus, and vitamin D may help prevent osteoporosis, which can lead to compression fractures and low back pain.
• Manage the stress in your life, both at home and at work.

Whether your low back pain is mild or severe, home treatment will be an important part of your care.

Acute low back pain

• Try first aid for back pain in the first few days after back pain starts.
• Ease back into your daily activities. Studies show that bed rest does not relieve pain better than staying active. And bed rest can lead to a decrease in your ability to function.² But you may need to reduce your activity level. Avoid activities that cause back pain, such as prolonged sitting.
• Use nonprescription pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and apply ice or heat to your back to reduce back pain.
• A medium-firm mattress is likely to be more comfortable than either a soft or a firm mattress.¹⁴

Back problems: Proper lifting

Fitness: Increasing core stability

Low back pain: Exercises to reduce pain

Ongoing (chronic) low back pain

To help relieve chronic low back pain, always try to:

• Exercise to help relieve back pain. See a physical therapist or other spine specialist for exercises specific to your condition. Studies show that doing exercises can help people with chronic low back pain return to their normal daily activities.¹⁵
• Reduce the stress in your life.
• Get the support you need. Work with your doctor to come up with a chronic pain treatment plan. Ask family members or friends when you need a helping hand.
• Achieve and maintain a healthy weight.
• Try not to bend or twist your back as you lie down.
• Avoid tobacco smoke. Smoking slows tissue healing.

Think through your daily activities and change those that may be causing back pain. Your list might include lifting a small child throughout the day, a long commute to work, sitting in front of a computer all day, wearing high-heeled shoes, or doing yard work or landscaping work.

Many people who have low back pain, or leg pain from a low back problem, notice that the pain interferes with sexual activity. Talk with your partner and perhaps your doctor about this. You may be able to find different positions for sex that are comfortable for you.

If you think your activities at work are causing back problems, information is available from your human resources department or the Occupational Health and Safety Administration (OSHA) within the U.S. Department of Labor. For contact information, see the Other Places to Get Help section of this topic. Many businesses require or recommend the use of back belts at work, although there is no evidence that they reduce back injury.^{16, 17}

Medicine can decrease low back pain and reduce muscle spasms in some people. But medicine alone is not an effective treatment for low back pain. It should be used along with other treatments, such as exercise and physical therapy.

Medication Choices

There are several medicines your doctor may recommend, depending on how long you have had pain, what other symptoms you have, and your medical history. The medicines recommended most often are:

• Acetaminophen.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Muscle relaxants.
• Opiates.
• Antidepressants.

Anesthetic or corticosteroid injections have all been prescribed for chronic low back pain, but they have not been researched enough to know whether they are effective for most people.

You may also hear of people having facet joint injections of anesthetic or corticosteroid for low back pain, but research has shown this to be ineffective or even harmful.

What To Think About

When making treatment decisions, bear in mind that medicines that work for some people don't work for others. Let your doctor know if the medicine you are taking is not effective. There may be another option to help control your back pain.

Anticonvulsants are sometimes used to treat low back pain, even though there isn't strong evidence that they help.

Botulinum toxin A (Botox) injection into the back muscles for chronic low back pain is an experimental treatment.

Surgery is seldom used to treat low back pain. In most cases, the cause of low back pain cannot be helped by surgery.

Most back surgeries are performed to treat herniated discs. Still, most people with herniated discs do not need surgery. Herniated disc surgery may be used when a disc problem is causing severe and disabling sciatica. For more information, see the topic Herniated Disc

Surgery is sometimes done to treat spinal stenosis if it is causing severe symptoms. As with herniated disc, most people with spinal stenosis do not need surgery. For more information, see the topic Lumbar Spinal Stenosis.

Surgery may also be considered in more unusual situations, as in the case of:

• A spinal fracture caused by an injury.
• A spinal infection, such as osteomyelitis or an abscess.
• An "unstable spine" condition, such as spondylolisthesis.
• A spinal tumor.

Rehabilitation after surgery

A comprehensive rehabilitation program is very important after most back surgery. As you regain flexibility, recondition your back and stomach muscles, and increase your endurance for activity, you increase your chances of treatment success.

If you are unable or unwilling to commit to physical therapy after surgery, you may not be a good candidate for surgery.

Surgery Choices

If nonsurgical treatment has not been successful and your doctor suggests that you consider surgery, the type of procedure he or she recommends will depend on the cause of your back problems and the experience and preference of the surgeon.

• Herniated disc surgery removes disc material that is pressing on the spinal cord or a nerve root. For more information, see:

  Should I have surgery for a herniated disc?

• Spinal stenosis surgery (spinal decompression with or without spinal fusion) widens a narrowed spinal canal and relieves pressure on the spinal cord or a nerve root. For more information, see the topic Lumbar Spinal Stenosis.
• Spinal fusion (arthrodesis) for spondylolisthesis and other "unstable spine" conditions joins vertebrae together to relieve pressure on the spinal cord or a nerve root and to stabilize the spine.
• Vertebroplasty or kyphoplasty relieves pain from compression fractures.
• Surgery for infection includes debridement with or without joint fusion, or drainage of an abscess.
• Disc replacement surgery removes a spinal disc that is severely damaged by degenerative disc disease (DDD), and replaces it with an artificial disc. This is currently only for carefully selected patients, and it is done by specially trained surgeons.
• Surgery for spinal tumors includes tumor removal and stabilization with or without fusion.

What To Think About

Back surgery is not always successful. Depending on the condition, you may still have back pain after surgery.

If you and your doctor are considering surgery, get as much information as you can about possible outcomes, and consider whether you will be willing to participate in a physical therapy program after surgery. It is also a good idea to get a second opinion before you decide to have surgery.

You can choose from a number of alternative therapies for treating your low back pain. Some are short-term "repair" treatments, and others give you the self-care tools for managing your back symptoms over a lifetime. Because many of these treatments are new or not yet well researched, they may not be covered by health insurance.

Comprehensive rehabilitation programs offer a variety of treatments and specialists. A comprehensive rehabilitation program is considered one of the most effective approaches for treating chronic low back pain, and may be your best bet for finding the right combination of treatments.⁴

Other therapies for lower back treatment

• Exercise therapy for back pain is considered an effective approach for treating and managing chronic low back pain.⁴ Daily activity and physical therapy exercises can be effective in relieving back pain and can lead to long-term improvement for low back pain. Also see:

  Fitness: Increasing core stability.

  Low back pain: Exercises to reduce pain.

• Cognitive-behavioral therapy may reduce both acute and chronic low back pain and disability.^{2, 4}
• Back school is an educational program that has shown mixed results but is considered likely to be beneficial for treating chronic low back pain.⁴
• Intradiscal electrothermic therapy (IDET) treats chronic low back pain related to a damaged spinal disc.
• Spinal cord stimulation may be used for some types of chronic pain when other treatments have failed, but there is not strong evidence that it works.¹⁸

Experimental treatments

New and experimental treatments are constantly being developed and offered to people with low back pain. If you are considering such a treatment, be sure to ask your doctor for the scientific evidence that shows the treatment's effectiveness and safety, as well as the results of his or her own practice.

The following therapies are experimental and not widely used. Research continues on these therapies.

• Surgery to replace a ruptured or herniated disc with an artificial disc has been approved by the U.S. Food and Drug Administration (FDA). Long-term studies have not been done.¹⁹
• Botulinum toxin (Botox) injection may relax pain muscle spasms in the low back.
• Radiofrequency ablation of nerves may reduce chronic low back pain in some people by preventing pain signals from reaching the brain. It is sometimes used for pain from problems with the small joints in the spine called facet joints.
• An intrathecal pain pump is a small tube inserted under the skin and deeper tissues along the midline of the back, which connects to a small reservoir of medicine inserted under the skin of your belly. The medicine is regularly delivered to the area of pain through the tube. This method of pain control is not yet widely used, but results are promising.²⁰

Complementary therapies and self-care

The following complementary therapies are commonly used for relieving low back pain.

• Massage may reduce low back pain, especially when combined with exercises and back care education.²¹
• Spinal manipulation is likely to help either acute or chronic low back pain.^{2, 4} While they differ in their training, osteopaths, chiropractors, physiatrists, and specially trained physical therapists can all perform spinal manipulation. Spinal manipulation usually has its greatest impact after one treatment, so multiple treatments are seldom necessary.⁷ Learn more about chiropractic and osteopathic manipulative treatment. One comparison has shown that people receiving osteopathic manipulative treatment may need less medicine to control their pain than those receiving standard treatment such as pain medicine and physical therapy.²² For more information, see:

  Should I have spinal manipulative therapy to treat low back pain?

• Biofeedback has not been well studied as a treatment for low back pain. But recent research has not shown that biofeedback is effective for controlling low back pain.^{2, 4}
• Acupuncture may help decrease pain and increase activity. Some studies show that acupuncture reduced pain and disability related to back problems more than usual treatment.^{8, 9} Another summary of several studies showed that acupuncture reduced pain and increased the ability to be active, but not any more than other treatments.¹⁰
• Acupressure uses pressure on certain points in the body to decrease symptoms. Small studies suggest that acupressure reduces pain and allows a person to be more active.²³
• Relaxation techniques can help reduce muscle tension, stress, and depression.
• Yoga is another way of staying active, while also helping with relaxation and stress management. It is not clear whether yoga is more helpful than other activity or treatment for low back pain.²⁴ There are different types of yoga. Talk to your doctor or physical therapist before you start a yoga program.

Organizations

• Back Problems and Injuries
• Chronic Pain
• Herniated Disc
• Lumbar Spinal Stenosis
• Osteoarthritis
• Scoliosis

Citations

1. Carragee EJ, Hannibal M (2004). Diagnostic evaluation of low back pain. Orthopedic Clinics of North America, 35(2004): 7–16.

2. Koes B, Van Tulder M (2006). Low back pain (acute), search date November 2004. Online version of Clinical Evidence (15).

3. Datta D, et al. (2005). Low back pain. In ED Harris Jr et al., eds., Kelley's Textbook of Rheumatology, 7th ed., vol. 1, pp. 588–600. Philadelphia: Elsevier Saunders.

4. Van Tulder M, Koes B (2006). Low back pain (chronic), search date November 2004. Online version of Clinical Evidence (15).

5. Hay EM, et al. (2005). Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: A randomised clinical trial in physiotherapy practice. Lancet, 365(9476): 2024–2030.

6. Goldby LJ, et al. (2006). A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder. Spine, 31(10): 1083–1093.

7. Hadler NM (2005). Low back pain. In WJ Koopman, ed., Arthritis and Allied Conditions, 15th ed., vol. 2, pp. 2073–2086. Philadelphia: Lippincott Williams and Wilkins.

8. Abramowicz M (2006). Acupuncture. Medical Letter on Drugs and Therapeutics, 48(1234): 38–39.

9. Haake M, et al. (2007). German acupuncture trials (GERAC) for chronic low back pain. Archives of Internal Medicine, 167(17): 1892–1898.

10. Furlan AD, et al. (2007). Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews (2).

11. Abraham I, Killackey-Jones B (2002). Lack of evidence-based research for idiopathic low back pain. Archives of Internal Medicine, 162(13): 1442–1444.

12. Hu SS, et al. (2006). Lumbar disc herniation section of Disorders, diseases, and injuries of the spine. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 246–249. New York: McGraw-Hill.

13. U.S. Preventive Services Task Force (2005). Primary care interventions to prevent low back pain in adults: Recommendation statement. Available online: http://www.ahrq.gov/clinic/3rduspstf/lowback/lowbackrs.htm.

14. Kovacs FM, et al. (2003). Effect of firmness of mattress on chronic non-specific low-back pain: Randomised, double-blind, controlled, multicentre trial. Lancet, 362(9396): 1599–1604.

15. Hayden JA, et al. (2007). Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews (2).

16. Wassell JT, et al. (2000). A prospective study of back belts for prevention of back pain and injury. JAMA, 284(21): 2727–2732.

17. Deyo RA, Weinstein JN (2001). Low back pain. New England Journal of Medicine, 344(5): 363–370.

18. Mailis-Gagnon A, et al. (2007). Spinal cord stimulation for chronic pain. Cochrane Database of Systematic Reviews (2).

19. U.S. Food and Drug Administration (2004). FDA approves artificial disc; another alternative to treat low back pain. FDA Talk Paper T04-45. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01320.html.

20. Deer T, et al. (2004). Intrathecal drug delivery for treatment of chronic low back pain: Report from the National Outcomes Registry for Low Back Pain. Pain Medicine, 5(1): 6–13.

21. Furlan AD, et al. (2007). Massage for low-back pain. Cochrane Database of Systematic Reviews (2).

22. Andersson GB, et al. (1999). A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine, 341(19): 1426–1431.

23. Hsieh LL, et al. (2006). Treatment of low back pain by acupressure and physical therapy: Randomised controlled trial. BMJ, 333(7543): 696–700.

24. Graves N, et al., (2004). Does yoga speed healing for patients with low back pain? Journal of Family Practice, 53(8): 661–662.

Other Works Consulted

• Cailliet R (2003). Low Back Disorders: A Medical Enigma. Philadelphia: Lippincott Williams and Wilkins.

• Chaiamnuay S, et al. (2006). Risks versus benefits of cyclooxygenase-2-selective nonsteroidal antiinflammatory drugs. American Journal of Health-System Pharmacy, 63(19): 1837–1851.

• Chou R, Huffman LH (2007). Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147(7): 492–504.

• Thorson DC, et al. (2006). Health Care Guideline: Adult Low Back Pain, 12th ed., pp. 1–65. Bloomington, MN: Institute for Clinical Systems Improvement.