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New Treatment Guidelines for Back Pain Stress Non-Drug Interventions, Physical Movement and Watchful Waiting

Story at-a-glance -

  • Back pain is one of the most common health complaints across the globe, and the No. 1 cause of job disability. It’s also one of the most common reasons triggering opioid dependence
  • The American College of Physicians’ updated treatment guidelines for acute and chronic low back pain sidesteps medication as a first-line treatment and recommends non-drug therapies instead
  • Exercise and functional movement are the most effective prevention and treatment strategies for most types of back pain

By Dr. Mercola

Back pain is one of the most common health complaints across the globe, and the No. 1 cause of job disability. It's also one of the most common reasons triggering opioid dependence, the side effects of which can be lethal.

In 2013, 16,000 Americans died from overdosing on prescription painkillers.1 And, if you have back pain and suffer depression or anxiety you're at particularly high risk for opioid abuse and addiction, research shows.2

While it can be quite debilitating, 75 to 80 percent of low-back pain cases resolve within 2 to 4 weeks,3 even without treatment.

This is particularly true for mechanical low-back pain (LBP), which is the second most common symptom-related reason for doctor's visits in the U.S. LBP is typically preceded by some form of injury or strain, such as lifting, twisting while holding something heavy, a car collision or a fall.  

Prolonged sitting is also on this list, which may explain why simply standing up more is part of the solution in many cases. Medscape4 lists a number of tests used to diagnose mechanical LBP, as well as a number of ways to manage this type of pain. This includes:

  1. Controlling inflammation
  2. Restoring range of motion
  3. Improving muscle strength and endurance
  4. Coordination training and cardiovascular reconditioning
  5. Maintaining an exercise program

Activity Is the First Line of Treatment

As you can see from the list above, the emphasis is on functional movement and exercise. This holds true for most forms of back pain, not just LBP. This makes sense since your body needs regular activity to remain pain-free.

For example, when you sit for long periods of time, you typically end up shortening your iliacus, psoas and quadratus lumborum muscles that connect from your lumbar region to the top of your femur and pelvis.

When these muscles are shortened it can cause severe pain upon standing, as they will effectively pull your lower back (lumbar) forward. When there's insufficient movement in your hip- and thoracic spine, you also end up with excessive movement in your lower back.

Most people tend to "baby" the pain and avoid moving about as much as possible, but in most cases, this is actually contraindicated. As previously reported in The Guardian:5

"Despite a host of treatment options including acupuncture, manual therapies, drugs, injections and surgery, nothing is more likely to work than staying active. Just when you least feel like it, and it hurts the most, is when experts say you have to get moving ...

Lesley Colvin, a pain medicine specialist in Edinburgh, says the best evidence is for exercise. 'If I had back pain, I'd do exercise that strengthens the core, such as yoga, pilates and stretching.' [Dr. Christopher] Williams advises: 'Avoid bed rest' ..."

Indeed, yoga has demonstrated its usefulness in a number of studies. In one, taking one yoga class per week resulted in greater improvements in function compared to medication or physical therapy. 6 The Yoga Journal has an online page demonstrating helpful poses.7

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Exercise Is Also Best Form of Prevention

Exercise is also the most effective way to prevent back pain in the first place, or a relapse, according to a recent scientific review of 21 studies.8 Contraptions such as back belts and shoe insoles had no discernible effect on people's risk of developing back pain.

Among people who had a history of back pain, those who exercised had a 25 percent to 40 percent lower risk of having another episode within a year than those who did no exercise.

Strength exercises, aerobics, flexibility training and stretching were all beneficial in lowering the risk of recurring pain. The video above, featuring Lisa Huck, demonstrates and explains the benefits of dynamic movement, and how it can help prevent and treat back pain.

New Treatment Guidelines Stress Non-Drug Interventions for Back Pain

As noted in a recent New York Times article,9 doctors are increasingly starting to prescribe activity in combination with a wait-and-watch approach for back pain patients.

On February 14, the American College of Physicians also issued updated treatment guidelines10 for acute, subacute and chronic low back pain, now sidestepping medication as a first-line treatment and recommending non-drug therapies instead. This is a significant change, and one that could potentially save thousands of lives by avoiding opioid addiction.

The new guidelines include three primary recommendations (below), all of which focus on alternative treatments and physical activity, leaving painkillers as a very last resort. Even in the rare case when an opioid is given, it should only be prescribed in the lowest dose and for the shortest duration possible.

Steroid injections and acetaminophen are also discouraged, as studies suggest neither is helpful or beneficial. Acetaminophen does not lower inflammation, and a review of the research11 shows steroids are on par with placebo when it comes to treating back pain in the long term.

1. "Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat … massage, acupuncture, or spinal manipulation … If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants …

2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction … tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation …

3. In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy.

Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients … "

Simple Stretching Exercises May Help Sciatic Pain

According to Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University and one of the authors of the new guidelines, there's really no need to see a doctor at all for acute back pain, defined as pain that lasts up to four weeks and does not radiate down the leg. He likens it to a case of the common cold — most of the time you simply have to wait it out.

If you have sciatic nerve pain, certain stretching exercises can be helpful. Sciatica results when your sciatic nerve gets pinched in your lower back. The pain is typically felt as originating in your buttock, radiating down your thigh. Your sciatic nerve runs through your piriformis, a muscle located deep in your glutes.

If the piriformis gets too tight, it can impinge the sciatic nerve, causing pain, tingling, and numbness in your leg. Oftentimes, simply stretching your piriformis may be enough to reduce this pain. For instructions and demonstrations, please see my previous article on exercises for sciatic nerve pain.

Scans and Surgery Are Useless for Most Cases of Back Pain

According to the American College of Physicians, scans like MRIs are also to be avoided, as they're "worse than useless" for diagnosing back pain. Exceptions include cases of known trauma to the spine and where there are warning signs of underlying disease causing the pain (such as cancer).

Contrary to popular belief, disc degeneration does not cause back pain, so getting a scan and receiving a structural diagnosis of a bulging disc for example, is not going to be very helpful, at least not in terms of dictating a course of treatment for your pain. In many cases, such a diagnosis may simply lead to unnecessary surgery, which in many cases sends patients in a downward spiral of increasing pain and reduced mobility.

According to the medical literature, spinal fusions for back pain have a success rate of about 20 to 25 percent. For 75 to 80 percent of these patients, the surgery simply results in lifelong pain and suffering.

Dr. David Hanscom, an orthopedic surgeon with a practice in Seattle, discussed these and other facts in a 2015 interview, along with a novel system for treating back pain that addresses a wide spectrum of contributing factors, including sleep hygiene, nutrition, relaxation, physical therapy and emotional processing through expressive writing exercises.

Live Life and Avoid Medicalizing Your Pain 

Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, told The New York Times:12 

"What we need to do is to stop medicalizing symptoms. Pills are not going to make people better … [Y]oga and tai chi, all those things are wonderful, but why not just go back to your normal activities? I know your back hurts, but go run, be active, instead of taking a pill."

While this may sound harsh to some of you, it's actually really good advice. As noted by Dr. Steven Atlas, an associate professor at Harvard Medical School who wrote an accompanying editorial about the guidelines, "We are moving away from simple fixes like a pill to a more complex view that involves a lot of lifestyle changes," and that is certainly a much-needed turnaround.

Non-Exercise Activity May Be Part of Long-Term Solution for Back Pain

Keep in mind that part of "staying active" includes avoiding sitting as much as possible. While you may be more drawn to lying down rather than standing and moving around, the latter is likely to be more beneficial. I can vouch for the effectiveness of this strategy myself. I suffered from low-back pain for many years and tried a host of treatments, including chiropractic, massage, stretching, grounding, back-strengthening and posture-improving exercises and using an inversion table.

Nothing got to the root of the problem — until I learned about the hazards of sitting and began standing more. This was a completely unexpected yet pleasant surprise. Be aware that your pain may indeed worsen initially. It did for me as well. But once I reduced my 12 to 14 hours of daily sitting to less than an hour, it quickly vanished. If you have a desk job, consider investing in a stand-up desk.

Non-Drug Solutions for Pain Relief

It's extremely important to be fully aware of the addictive potential of opioid drugs, and to seriously weigh your need for them. There are many other ways to address pain. Below is a long list of suggestions. Clearly, there are times when pain is so severe that a narcotic pain reliever may be warranted. But even in those instances, the options that follow may allow you to at least reduce the amount you take, or the frequency at which you need to take them. 

If you are in pain that is bearable, please try these options first, before resorting to prescription painkillers of any kind. If you need a pain reliever, consider an over-the-counter (OTC) option. Research13 shows prescription-strength naproxen (Naprosyn, sold OTC in lower dosages as Aleve) provides the same pain relief as more dangerous narcotic painkillers.

However, while naproxen may be a better alternative to narcotic painkillers, it still comes with a very long list of potential side effects,14 and the risks increase with frequency of use.

Eliminate or radically reduce most grains and sugars from your diet

Avoiding grains and sugars will lower your insulin and leptin levels and decrease insulin and leptin resistance, which is one of the most important reasons why inflammatory prostaglandins are produced. That is why stopping sugar and sweets is so important to controlling your pain and other types of chronic illnesses.

Take a high-quality, animal-based omega-3 fat

Omega-3 fats are precursors to mediators of inflammation called prostaglandins. (In fact, that is how anti-inflammatory painkillers work, by manipulating prostaglandins.)

Good sources include wild caught Alaskan salmon, sardines andanchovies, which are all high in healthy omega-3s while being low in contaminants such as mercury. As for supplements, my favorite is krill oil, as it has a number of benefits superior to fish oil.

Optimize your sun exposure and production of vitamin D

Optimize your vitamin D by getting regular, appropriate sun exposure, which will work through a variety of different mechanisms to reduce your pain. Sun exposure also has anti-inflammatory and pain relieving effects that are unrelated to vitamin D production, and these benefits cannot be obtained from a vitamin D supplement.

Red, near-, mid- and far-infrared light therapy (photobiology) and/or infrared saunas may also be quite helpful as it promotes and speeds tissue healing, even deep inside the body.

Medical cannabis

Medical marijuana has a long history as a natural analgesic and is now legal in 28 states. You can learn more about the laws in your state on medicalmarijuana.procon.org.15


Kratom (Mitragyna speciose) is another plant remedy that has become a popular opioid substitute.16 In August, the U.S. Drug Enforcement Administration issued a notice saying it was planning to ban kratom, listing it as Schedule 1 controlled substance.

However, following massive outrage from kratom users who say opioids are their only alternative, the agency reversed its decision.17

Kratom is likely safer than an opioid for someone in serious and chronic pain. However, it's important to recognize that it is a psychoactive substance and should not be used carelessly. There's very little research showing how to use it safely and effectively, and it may have a very different effect from one person to the next.

Also, while it may be useful for weaning people off opioids, kratom is in itself addictive. So, while it appears to be a far safer alternative to opioids, it's still a powerful and potentially addictive substance. So please, do your own research before trying it.

Emotional Freedom Techniques (EFT)

EFT is a drug-free approach for pain management of all kinds. EFT borrows from the principles of acupuncture in that it helps you balance out your subtle energy system. It helps resolve underlying, often subconscious, and negative emotions that may be exacerbating your physical pain.

By stimulating (tapping) well-established acupuncture points with your fingertips, you rebalance your energy system, which tends to dissipate pain.

Meditation and Mindfulness Training

Among volunteers who had never meditated before, those who attended four 20-minute classes to learn a meditation technique called focused attention (a form of mindfulness meditation) experienced significant pain relief — a 40 percent reduction in pain intensity and a 57 percent reduction in pain unpleasantness.18

K-Laser, Class 4 Laser Therapy

If you suffer pain from an injury, arthritis or other inflammation-based pain, I'd strongly encourage you to try K-Laser therapy. It can be an excellent choice for many painful conditions, including acute injuries. By addressing the underlying cause of the pain, you will no longer need to rely on painkillers.

K-Laser is a class 4 infrared laser therapy treatment that helps reduce pain, reduce inflammation and enhance tissue healing — both in hard and soft tissues, including muscles, ligaments or even bones. The infrared wavelengths used in the K-Laser allow for targeting specific areas of your body and can penetrate deeply into the body to reach areas such as your spine and hip.


Many studies have confirmed that chiropractic management is much safer and less expensive than allopathic medical treatments, especially when used for pain such as low back pain.

Qualified chiropractic, osteopathic and naturopathic physicians are reliable, as they have received extensive training in the management of musculoskeletal disorders during their course of graduate healthcare training, which lasts between four to six years. These health experts have comprehensive training in musculoskeletal management.


Research has discovered a "clear and robust" effect of acupuncture in the treatment of back, neck and shoulder pain, and osteoarthritis and headaches.

Physical therapy

Physical therapy has been shown to be as good as surgery for painful conditions such as torn cartilage and arthritis.

Foundation Training

Foundation training is an innovative method developed by Dr. Eric Goodman to treat his own chronic low back pain. It's an excellent alternative to painkillers and surgery, as it actually addresses the cause of the problem.


A systematic review and meta-analysis published in the journal Pain Medicine included 60 high-quality and seven low-quality studies that looked into the use of massage for various types of pain, including muscle and bone pain, headaches, deep internal pain, fibromyalgia pain and spinal cord pain.19

The review revealed massage therapy relieves pain better than getting no treatment at all. When compared to other pain treatments like acupuncture and physical therapy, massage therapy still proved beneficial and had few side effects. In addition to relieving pain, massage therapy also improved anxiety and health-related quality of life. 


Astaxanthin is one of the most effective fat-soluble antioxidants known. It has very potent anti-inflammatory properties and in many cases works far more effectively than anti-inflammatory drugs. Higher doses are typically required and you may need 8 milligrams (mg) or more per day to achieve this benefit.


This herb has potent anti-inflammatory activity and offers pain relief and stomach-settling properties. Fresh ginger works well steeped in boiling water as a tea or grated into vegetable juice.


In a study of osteoarthritis patients, those who added 200 mg of curcumin a day to their treatment plan had reduced pain and increased mobility. A past study also found that a turmeric extract composed of curcuminoids blocked inflammatory pathways, effectively preventing the overproduction of a protein that triggers swelling and pain.20


Also known as boswellin or "Indian frankincense," this herb contains specific active anti-inflammatory ingredients.


This enzyme, found in pineapples, is a natural anti-inflammatory. It can be taken in supplement form but eating fresh pineapple, including some of the bromelain-rich stem, may also be helpful.

Cetyl Myristoleate (CMO)

This oil, found in fish and dairy butter, acts as a joint lubricant and anti-inflammatory. I have used this for myself to relieve ganglion cysts and carpal tunnel syndrome. I used a topical preparation for this.

Evening Primrose, Black Currant and Borage Oils

These contain the essential fatty acid gamma-linolenic acid (GLA), which is particularly useful for treating arthritic pain.

Cayenne Cream

Also called capsaicin cream, this spice comes from dried hot peppers. It alleviates pain by depleting the body's supply of substance P, a chemical component of nerve cells that transmits pain signals to your brain.

Methods such as hot and cold packs, aquatic therapy, yoga, various mind-body techniques and cognitive behavioral therapy21 can also result in astonishing pain relief without drugs.


Walking barefoot on the earth may also provide a certain measure of pain relief by combating inflammation.