Low Back Pain? Explore Your Options for Easing the Ache

You may not need surgery or medications to solve your low back pain. New guidelines are endorsing non-drug therapies first.

low back pain

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

© Skypixel | Dreamstime.com

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


…to reduce your risk of nonalcoholic fatty liver disease and liver damage—conditions that can produce low back pain as a symptom:

  1. Maintain an optimal weight. If you’re overweight or obese, follow the dietary and exercise recommendations of your healthcare team to help you lose weight. Obesity is a key driver of nonalcoholic fatty liver disease and has also been identified as a risk factor for liver cancer.
  2. Follow a Mediterranean-style diet. That means a diet rich in fruits, vegetables and whole grains, with limited consumption of saturated fat, added sugars, and processed foods.
  3. Work with your doctor to optimize your triglycerides, cholesterol, blood sugar, and blood pressure through lifestyle changes and, if necessary, medications.
  4. Avoid heavy alcohol use. If you drink, limit your intake to no more than two standard drinks a day. (A standard drink equals 12 ounces of beer, 8 to 9 ounces of malt liquor, 5 ounces of wine, or 1½ ounces of 80-proof distilled spirits.)
  5. Use medications like acetaminophen (Tylenol) with caution, especially if you have liver disease or drink alcohol. Overuse of acetaminophen can cause liver damage.

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.


  • Lift properly. To avoid injury, bend at the knees, not at the waist, and engage your leg muscles when you lift something. Hold whatever you’re lifting close to your body.
  • Sit/stand properly. Practice good posture by keeping your chest raised, your shoulders back, and maintaining a straight vertical alignment from the top of your head, through the center of your body and to your feet.
  • Work with your healthcare team to maintain a healthy weight and get rid of your “beer belly.” A protruding stomach can pull your body forward and place more strain on your lower back.
  • low back pain -- knee hug

    Knee-hugs from a lying-down position can stretch the muscles that may contribute to low back pain.

  • If you have back pain or another painful condition, seek a medical evaluation before pursuing acupuncture, spinal manipulation, or massage, to rule out any potentially serious conditions that might require other treatment.
  • Find out if your insurance provider covers the cost of acupuncture, massage, spinal manipulation, or other non-pharmacologic treatments for low back pain.
  • low back pain -- press-up

    Exercises like this one are important in preventing low back pain.

  • Try these exercises to improve flexibility and ease lower-back pain (check with your healthcare provider first to make sure they’re suitable for you; hold each exercise for 20 seconds, and repeat each two to three times):
    • Knee hugs: Lie on your back with your knees about a foot apart. Pull your knees slowly toward your chest, keeping your back flat on the floor.
    • Press-ups: Lie face-down, and press your upper body 
up off the floor, keeping your waist flat 
on the floor.

Illustrations: Alayna Paquette

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

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Jim Black

Jim Black has served as executive editor of Cleveland Clinic’s Men’s Health Advisor newsletter since 2005. He has written about prostate diseases, men’s health, cardiovascular disease, cancer, and a wide … Read More

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