Fortunately, most episodes of back pain—about 90 percent—are acute and will clear up with little or no treatment within six to eight weeks, and often sooner, reducing the need for medical intervention. Back pain that cannot be relieved in any position, which persists unabated even when you’re not moving, or which shows no improvement at all after a week merits medical attention. Here's a guide to the treatment options, beginning with self-care measures you can do at home.
As long as you are not experiencing severe or unremitting back or leg pain or other symptoms that might indicate a serious health condition (such as severe nighttime pain or pain that worsens when lying down, weight loss, bowel or bladder dysfunction, or fever), you can safely try self-treatment. Take the following steps:
- Rest. Lying down takes pressure off the spine and usually lessens pain. The best postures in bed are lying on your side in the fetal position with a pillow between your knees, or on your back with knees flexed, using a pillow to support the legs. Most experts advise limiting bed rest to one or two days. Longer inactivity may do more harm than good by weakening muscles. It’s better to get out of bed and move around as soon as you can do so with reasonable comfort, even if some pain persists. Until the pain fully disappears, avoid lifting, bending, vigorous exercise, or other activities that stress the back.
- Ice or cold pack. After a sudden injury with pain limited to the back area, immediately applying ice can be therapeutic. In addition to relieving pain, ice reduces internal bleeding and swelling by decreasing blood flow. An ice bag or commercial cold pack should be used for 10 to 20 minutes every two hours for the first 48 hours after injury (while you’re awake). The 20-minute limit is important to avoid the risk of frostbite. Another approach is to massage the painful area with an ice pack.
- Heat. After an acute back injury, it’s best to wait 48 hours before applying heat. However, chronic back pain or a more widespread backache that begins sometime after a back injury may be eased by relaxing muscles with a hot bath, heating pad, or hot, moist compresses.
- Over-the-counter medications. Nonsteroidal anti-inflammatory drugs (NSAIDs)—for example, aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve)—or acetaminophen (Tylenol) can help alleviate discomfort, reduce inflammation, or both. Be sure to read the labels and follow instructions carefully. Even over-the-counter medications can cause side effects if over used. NSAIDs other than aspirin carry heart risks, and you should not drink alcohol while taking acetaminophen.
- Traction, corsets, and braces. Little evidence supports the use of traction or corsets, though temporary use of a corset with built-in supports may be helpful during recovery following back surgery or during activities that have to be performed even when still experiencing pain. Whether back braces help in treating back pain is unclear, since research results have been conflicting.
If you have severe back pain that lasts more than a few days, mild to moderate back pain that does not respond to self-treatment, or other symptoms that might indicate a serious health condition, it is important to visit your primary-care doctor.
Your doctor is likely to advise the self-treatment techniques described above and may also recommend a short course of medication or other treatment. In general, limiting the amount of bed rest and pain medication is the preferred approach to back pain management—a strategy supported by current research. Treatment guidelines from the American College of Physicians (ACP), updated in 2017, strongly encourage patients and doctors to consider using nondrug therapies for back pain before turning to medication.
If over-the-counter pain relievers prove to be inadequate, your doctor may prescribe something stronger. You and your doctor will want to balance the degree of pain relief from medications against their potential adverse effects.
Prescription drug options
For acute back pain, medications can be helpful in making people more comfortable. For chronic back pain, the efficacy of many drugs is less clear, and problems from them can be serious.
Your doctor may recommend a muscle relaxant, such as cyclobenzaprine (Amrix, Flexeril), methocarbamol (Robaxin), or metaxalone (Skelaxin). These drugs are not recommended as a first-line treatment for acute low back pain, however. The ACP guidelines note that in clinical studies, muscle relaxants provided only a small improvement in pain relief.
Further, muscle relaxants can have a sedating effect and cause dizziness, especially in older adults. You should not take them for more than one to two weeks, and people with a history of substance abuse or other mental health conditions should use them with great caution or not at all.
Sometimes anticonvulsants such as gabapentin (Gabarone, Neurontin) are prescribed for back pain, since these drugs affect the nervous system and alter the way in which the body perceives pain. However, a systematic review and meta-analysis of clinical trials on anticonvulsants for low back pain, published in the Canadian Medical Association Journal in July 2018, concluded that the drugs are ineffective for low back pain and have a high risk of adverse effects.
Finally, as a last resort when all other medications have failed, opioid drugs may be prescribed. Because these drugs are addictive, they should be used with caution, only for short periods, and under scrupulous medical supervision. Moreover, a clinical trial published in 2018 in the Journal of the American Medical Association reported that opioid treatment was no more effective at treating chronic back pain (or osteoarthritis) than non-opioid options.
When pain medications and other nonsurgical treatment strategies yield less-than-satisfying results for conditions such as sciatic pain, another option to consider is spinal injection therapy. This involves the injection of a powerful anti-inflammatory drug in the form of a corticosteroid, typically with an anesthetic.
The most comprehensive research to date has produced little evidence that injections are more effective than a placebo in providing short-term pain relief, and no research has evaluated long-term effectiveness. Despite this, they are still considered an integral part of the nonsurgical management of back pain, in part because of the lack of other nonsurgical options. Even short-term relief might be enough to allow you to engage in physical therapy, rehabilitative stretching, or an exercise program and help you return to normal activities sooner.
This article first appeared in the UC Berkeley Wellness Letter.
Also see Back Pain: An Ounce of Prevention.
Published November 21, 2018