Here's something completely different for low back pain

It's a question that has challenged generations of patients and their doctors. The answer has changed over the years. When I was in medical school in the early 1980s, bedrest for a week or more was often recommended for severe back pain. This sometimes included hospital admission. Then, research demonstrated that prolonged bedrest was actually a bad idea. It was no better (and often worse) than taking it easy for a day or two followed by slowly increasing activity, including stretching and strengthening the back.

Medications, including pain relievers, non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants were a standard part of the initial treatment of back pain. But, recommendations released in February 2017 urge doctors to change their approach to back pain once again.

Didn't I hear that NSAIDs don't work well for back pain?

You did. A 2017 study found that NSAIDs did not work well for back pain. But, recommendations released that same year take that conclusion even further: it may be best to avoid medications altogether — at least at the start.

The American College of Physicians' 2017  guidelines for the treatment of low back pain based on a review of more than 150 studies. The big news? Medications tend to have only temporary and modest benefits, so it makes sense to try something other than a pill. The specifics depend on the type and duration of back pain.

For new low back pain (lasting less than 12 weeks), try:

• heat
• massage
• acupuncture
• spinal manipulation, as with chiropractic care.

If these don't work, NSAIDs or a muscle relaxant are reasonable options. But given their potential to cause side effects and their modest benefit, they aren't the first choice.

For chronic low back pain (lasting 12 weeks or more), try:

• exercise (including stretching, improving balance, and strengthening core muscles)
• physical therapy
• acupuncture
• mindfulness-based programs intended to cope with or reduce stress.

Other approaches, such as tai chi, yoga, or progressive relaxation techniques may also be helpful.

If these don't work, treatment with NSAIDs, tramadol, or duloxetine is worth consideration. However, opioids should be avoided for chronic low back pain in most cases. 

It's important to emphasize these suggestions are for low back pain that might begin after an unusually strenuous workout or shoveling snow. It's not for serious causes of back pain such as a major injury, cancer, infection, or fractures (see "red flag" symptoms below).

What if the pain continues?

If pain persists despite these non-medication and medication-based treatments, your doctor may want to consider additional tests (such as MRI) or treatments. Remember, each person's situation is a little different, and even medications that don't work well on average, may work well for you.

You could see this coming?

It's been known for years that the vast majority of low back pain goes away on its own, regardless of treatment. So, the challenge has been to find something that safely eases symptoms while waiting for improvement.

How do I know it's nothing serious?

You don't. But, you should be reassured that the numbers are with you. Ninety-nine percent or more of people with low back pain do not have a serious cause. But to help make sure your back isn't in that small sliver of dangerous causes, doctors use the "red flag" questions:

• Have you ever been diagnosed with cancer?
• Have you experienced unexplained or unintentional weight loss?
• Do you have an abnormal immune system (due to disease or medications)?
• Do you use intravenous drugs?
• Have you had a fever recently?
• Have you had significant injury to your back recently?
• Have you had bladder or bowel incontinence?

These questions and a physical examination are intended to identify factors that would increase the chances that your back pain is due to infection, tumor, or other serious cause.

So, what?

These guidelines endorse an approach to treating a common ailment that only a few years ago would have seemed outrageous. The remedies recommended are not brand new; but discouraging medication use as an initial step is a big departure from prior recommendations. An email alert I received just after these guidelines were published included the headline: "Take two yoga classes and call me next month?" It may not be such a bad idea!

Medical practice rarely changes right away, and these guidelines may have relatively little impact in the short run. But I would not be surprised if non-pharmacological treatment of back pain becomes the norm over time. Many of my patients already seek out these treatments regardless of whether I recommend them. After all, the "usual" medications for low back pain are not all that effective and often cause trouble. It's time we recognize that there are other, better ways to help.