Back pain is big business. Affecting 619 million people worldwide in 2021, almost twice as many as in 1990, it’s estimated lower back pain cost the UK around £3.5 billion in healthcare, in one year alone. For sufferers, though, the true cost can be even higher. “It affects people mentally,” says Andy Marlow, a personal trainer and specialist in lower back pain rehabilitation who’s suffered from the condition himself. “I’ve had clients who are on the verge of suicide because of their back pain – that’s how they express it: I’m ready to throw myself out a window because I can’t get rid of this problem that’s affecting my whole life.”
Part of the issue is that there are dozens of competing treatments on offer, hundreds of self-professed experts selling their own cures, and very little consensus on what’s likely to work. In a recent review of over 300 studies, academics in Australia looked at the effectiveness of 56 different non-surgical options – ranging from stretching and massage to light therapy and anti-inflammatory drugs – and concluded that only a small fraction were effective. Chronic back pain, typically defined as the kind that persists for more than three months, saw some relief from five treatments, while acute back pain – usually caused by sprains or strains and lasting for a few weeks – was only effectively treatable through non-steroidal anti-inflammatory drugs (NSAIDS). It’s also worth noting, though, that in some of the treatments that “worked”, the effect was very small, and possibly outweighed by the downsides.
“If you look at something like antidepressants, we saw that they had an effect – but it was only around four points on a zero to 100 scale,” says Dr Aidan Cashin, the deputy director of the Centre for Pain IMPACT at Neuroscience Research Australia, and lead author of the study. “And when you look at the risks of them as a treatment, they’re quite high – so it’s important to consider potential for harm.”
This seems like a bleak outlook, but there’s still hope for sufferers, especially if they can be clear on what’s caused their back pain in the first place. “One fundamental problem is that large studies like this one put all types of lower back pain into the same category of ‘non-specific lower back pain’ – meaning that it doesn’t have a clear identifiable cause such as a fracture or a tumour,” Marlow explains. “But of course, there’s no such thing as non-specific back pain, just like there’s no such thing as non-specific knee pain.
“One of my clients, for instance, had poor ankle mobility from an operation to fix his club foot. He had spent his whole life moving through his spine whenever he had to pick something up, which led to a herniated disc. A key part of his rehab was improving his ankle mobility to direct stress away from his injured disc. What people need is a thorough assessment to determine the cause of their pain. Unfortunately, this takes time and skill. The assessment that I take my clients through takes three hours to complete, which for obvious reasons of cost and time, doesn’t fit very neatly into an overstretched medical system like the NHS.”
Clearly, the issue with this is that there’s no one-size-fits-all solution. “Some people go to the physio or an osteopath and get brilliant results, or do some exercises at home and never have another problem,” says Dr Sarah Mottram, a physiotherapist and founder of The Movement Works. “But other people spend years trying everything, and nothing seems to work.”
So what’s worth a try? Well, if your back pain has lasted for a while, then one important step is to rule out underlying medical causes. These are rare but could include anything from a fracture to a tumour, or infection in the spine. Once that’s done, here’s what the study – and the experts – say can help.
Exercise
The first thing to note is that there’s no one exercise – or combination of exercise – that’s a guaranteed fix for back pain, and it’s worth being wary of anyone who promises one. “I have one client who really benefits from Jefferson curls – a strength-building exercise where your spine’s curved under a load,” says Marlow. “But for anyone with disc herniation, that’s a terrible exercise that’s going to make things worse.” For many people, what works is incorporating regular movement into everyday life in a way they enjoy. “From a practical perspective, what seems to be important is that you’ll continue to do it,” says Dr Cashin. “So running, cycling and swimming can all be effective if they align with a person’s preferences, their capacity and what they can actually do.”
What’s also important, however, is learning to move in ways that support good back health. “I meet a lot of people who have never been shown how to brace their abs and hinge at the hips properly to lift things off the ground,” says Marlow. “That’s basic stuff that you would have learnt to do a deadlift in the gym. But other stuff is more personalised. You might have been told by a personal trainer that you should always squat with feet parallel, pointing forward, but in reality, your individual hip structure will determine where you place your feet to reduce stress on your spine.” In general, then, any low-intensity movement that you can do – walking included – is likely to be beneficial, but if you’re doing something more strenuous, it’s important to find a coach who understands back pain.
Tape
“Taping” – or applying kinesiology (K) tape to the lower back to provide support and feedback to the brain – was one of the more unexpected treatments shown to be beneficial in the recent review of studies. “The effect was fairly small, but it’s also a low-risk strategy if you’ve already tried other possibly effective options like exercise and spinal manipulative therapy (SMT),” says Dr Cashin. “Lots of the studies we looked at were conducted during the Olympics in Brazil, when K-tape really took off as a strategy.” The typical recommendation for lower back pain is to apply two long strips vertically to your lower back – a physiotherapist or sports therapist should be able to help.
SMT
Spinal manipulative therapy is a technique where practitioners use their hands – or a sometimes another device – to apply a controlled thrust to the spine. In the UK, it’s typically carried out by chiropractors, osteopaths, or specialist physiotherapists. “This comes in and out as recommended across different studies – our review found a small effect for it,” says Dr Cashin. “I think it’s also important not to rule out the psychological effect that can come from this kind of care being provided from long-term sufferers. This is also something we’ve seen in therapies that the evidence is weak for, such as acupuncture. It’s slightly beyond the scope of the study, but being in a caring, reassuring therapeutic environment can be very beneficial.”
If you’re going to try any of these therapies, find a specialist registered with the General Chiropractic Council, General Osteopathic Council, or Chartered Society of Physiotherapy.
NSAIDS
The use of non-steroidal anti-inflammatory drugs – such as ibuprofen – was the only treatment for acute lower back pain found to be effective in the review, typically by reducing inflammation caused by muscle strains, sprains, or arthritis. It’s important to bear in mind, though, that this doesn’t mean you should take paracetamol.
“The evidence shows that paracetamol is not effective in acute lower back pain,” says Prof Martin Underwood, a specialist in musculoskeletal disorders at the University of Warwick. “We don’t know if it’s effective in chronic back pain because the study evidence isn’t available. But if you look at the WHO guidance on lower back pain, they’ve got a special statement about paracetamol suggesting that the risk of gut, cardiac and kidney problems, particularly in older people, means there’s a strong implication that you shouldn’t take it.” Paracetamol does not have significant anti-inflammatory properties like NSAIDs.
Capsaicin
If you look at the treatments in the recent review, TRPV1 agonists might stand out. This refers to substances that act on the body’s transient receptor potential vanilloid 1 (TRPV1) channel, mainly known for sensing heat and pain. TRPV1 is also activated by capsaicin, the compound in chilli peppers that gives them their “hot” sensation – meaning that stimulating the receptor with heat can reduce pain sensitivity over time. “That’s why, if you eat chillies a lot, it blocks the pain sensors in your mouth,” says Prof Underwood. “And so it’s also why the WHO guidance includes cayenne pepper plasters.” Deep Heat or hot and cold packs may have a similar effect – and they’re a low-risk strategy.
Psychological help
This wasn’t studied in the recent review, as it hasn’t been researched much in the past, but there’s a growing agreement that dealing with the many other possible contributors to back pain on a psychological basis is a promising approach. “I’m hopeful that we’ll get a better understanding of what makes back pain affect different people in different ways,” says Dr Cashin. “But somewhere we’re seeing movement is where studies include a psychological and movement component. In Australia, this includes cognitive functional therapy and graded sensorimotor retraining, and in the US, pain reprocessing therapy – where we’re seeing meaningful and importantly sustained effects, compared with other therapies where the effect can diminish quite quickly.”
The treatments to avoid
Cortisone shots
Injections of cortisone – a form of steroid – can offer pain relief, but don’t help healing or prevent future problems. They’re best used infrequently, for shooting nerve pain from a ruptured disk (sciatica), or similar conditions.
“Looking at the latest high-quality systematic reviews, the evidence, although not definitive, suggests that on average they provide little to no benefit compared to sham or placebo procedures for people with non-specific lower back pain, and are unlikely to be a suitable treatment option.” says Dr Cashin. “WHO guidelines advise against use of glucocorticoids including cortisone shots,” says Prof Underwood. “It seems clear that there is nothing to support their use for lower back pain without ‘sciatica’.
“With sciatica, it is possible there may be a small benefit on pain, but not function, in the short term. So my view would be that the benefits are, at best, uncertain and small. When set against the potential risks from their routine use, that means that they’re probably best avoided.”
Cannabinoids
Some people report relief from taking these products, but it’s not recommended by the research: a 2021 review of studies from the International Association for the Study of Pain found a lack of sufficient evidence to recommend it. “While IASP cannot endorse the general use of cannabinoids for treatment of pain at this time, we do not wish to dismiss the lived experiences of people with pain who have found benefit from their use,” said Andrew Rice, a professor of pain research at Imperial College London, and chair of the IASP’s task force when the study was released. “This is not a door closing on the topic, but rather a call for more rigorous and robust research.”
The future of back pain treatments
“We all deal with pain in different ways, and people who’ve been living with it for a long time often lose hope,” says Dr Mottram. “But I think a huge factor going forward is going to be how the brain reconfigures itself in response to pain, and how we can train people to manage that. If you can change your neurophysiology to change how you move, think and feel, that might go a long way.” The Curable app, which takes users through cognitive behavioural therapy, guided meditations and pain reduction visualisations, is one good starting point.
“There’s still a lot of work to be done,” says Dr Cashin. “But for a long time, there’s been nothing in the pipeline and we’ve just had to focus on the basics. I’m very hopeful that in the next few years we’ll see more research into new therapies, and see them ready for implementation.”
In the meantime, there are plenty of useful things that everyone with chronic back pain can do. “Keep physically active as far as you can, continue normal social and family activities as far as you can within the limits of their pain.” says Prof Underwood. “For people who are working, try and stay at work. Many employers can make adjustments to help people with back pain stay at work.” There’s hope on the horizon – so for now, live the best life that you can.
