Low back pain? There's hope to avoid surgery.

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Just about everyone experiences low back pain at some point. You might strain your back while lifting, twist the wrong way, or sit or sleep in an awkward position.

The good news is that you probably can find relief without surgery or other invasive treatments—and maybe even without medications. In its new guidelines, the American College of Physicians (ACP) recommends non-drug treatments as a first option for managing low back pain, recognizing the potential risks associated with opioid pain relievers and other medications. The ACP also endorses several treatments that once were considered only as complementary or alternative to mainstream medical therapies.

Simply put, procedures that were once complementary—or what some would call alternative—and have since been proven by science are becoming more a part of medicine.

Pain Relief Without Pills

The ACP identifies three types of low back pain:

1. Acute (lasting less than four weeks)
2. Subacute (lasting four to 12 weeks)
3. Chronic (lasting more than 12 weeks)

Acute pain often results from a muscle or ligament strain, characterized by an aching or throbbing in the lower back. Chronic pain, especially as you age, may result from more gradual processes, such as degenerative spine disease. Low back pain doesn’t necessarily equate to a herniated disc that requires surgery.”

Historically, oral pain relievers such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs)—such as ibuprofen (Advil, Motrin) and naproxen (Aleve)—have been considered the first-line medical therapies for acute and subacute low back pain.

However, since most patients with acute or subacute low back pain improve over time regardless of treatment, they probably do not require medications at first, the ACP notes. So, the organization recommends initial non-pharmacologic treatments, such as heat therapy, massage, acupuncture or spinal manipulation (Annals of Internal Medicine, April 4, 2017).

Heat, massage, and acupuncture can loosen up painful, tight muscles and other tissues, and break up adhesions that restrict movement. Spinal manipulation balances the vertebrae and soft tissues of the back into a normal alignment through the application of varying degrees of force and movements.

For chronic low back pain, patients should try treatments like exercise/physical therapy, acupuncture, and mindfulness-based meditation before taking medications, the ACP guidelines recommend. Spinal manipulation and exercises such as yoga and tai chi, which help you to relax and improve your physical function, also may be helpful, although the data supporting their use to relieve chronic low back pain are not as strong, the ACP notes.

Keep in mind that acupuncture, massage therapy, and spinal manipulation encompass an array of styles. Choose only licensed practitioners of these treatments, and be sure your practitioner is aware of any medical problems you might have so you can use the style that’s appropriate for your medical condition.

When Pills Are Necessary

If non-drug treatments fail to provide sufficient pain relief, the ACP recommends NSAIDs and muscle relaxants as options for acute and subacute low back pain, but notes that acetaminophen is ineffective.

For patients with chronic low back pain that fails to respond adequately to non-pharmacologic treatments, NSAIDs are the first choice of medical therapy, followed by the antidepressant duloxetine (Cymbalta) or tramadol (Ultram) as second-line options, according to the guidelines.

Due to concerns about addiction and side effects, opioid pain relievers such as hydrocodone (Vicodin) and oxycodone (Oxycontin) should be considered only in patients with chronic low back pain who have failed these other treatments—and only if the benefits outweigh the risks, the ACP notes.

The Realities of Low Back Pain Treatment

Considering that no treatment for acute or subacute low back pain has proven to be vastly superior to others, patients and physicians should work together to find the right treatment, based on factors such as personal preference and insurance.

Chances are, you may need a combination of treatments to gain sufficient relief, and finding the right mix may take some trial and error. The main purpose of all treatments for acute and subacute low back pain is not necessarily to eliminate all your pain, but to reduce it enough so that you can resume your daily activities, Dr. DeMicco advises.

Whatever treatment you decide on, combine it with physical activity, whether it’s a structured physical therapy program or home exercises. Yes, low back pain can be debilitating, but you still have to move as much as your pain will allow.

Experts strongly stress, in fact, the benefits of staying active. Strict bed rest is generally a thing of the past, eschewed in favor of performing normal activities as tolerated along with relative rest.

This article was originally published in 2017. It has since been updated.