For the first time, the American College of Physicians is advising treating back pain with nondrug measures like tai chi, yoga, chiropractic, and massage before resorting to over-the-counter or prescription pain relievers.
The new advice comes as a new Consumer Reports nationally representative survey shows many people with back pain found alternative therapies useful. The survey of 3,562 adults found that almost 90 percent of those who tried yoga or tai chi said they were helpful; 84 percent and 83 percent, respectively, said the same of massage and chiropractic.
The new ACP guidelines, published in the Annals of Internal Medicine, call for the use of these nondrug treatments first, before using OTC painkillers like ibuprofen, and they also strongly discourage the use of prescription opioid painkillers due to the risk of addiction or overdose.
To develop the new guidelines, researchers evaluated 46 studies on back pain and medications and 114 studies on non-medication strategies.
Many of the recommendations are in keeping with the last set of guidelines—issued in 2007—but there are notable differences.
“The biggest shift is prioritizing non-pharmacologic therapies, using those first versus medication,” says Roger Chou, M.D., professor of medicine, Oregon Health & Science University School of Medicine, and lead author of the new reviews on back pain treatment. “This is the first guideline to really take this stance.”
Nondrug treatments like exercise, massage, spinal manipulation, and acupuncture were all recommended in the 2007 guidelines. Tai chi and mindfulness-based stress reduction are new additions.
The just-released ACP guidelines also move further away from what are sometimes dubbed "low-value treatments," such as doctors prescribing opioids, performing MRIs and surgeries, and giving injections (such as steroids, which reduce inflammation) to treat back pain.
“Despite the lack of evidence for their effectiveness, doctors are increasing their use of low-value treatments,” says Steven Atlas, M.D., a primary care internist at Massachusetts General Hospital, who wrote an editorial to accompany the guidelines.
For low back pain that lasts for four weeks or less (which is considered acute) or up to 12 weeks (subacute), you may not need to see a doctor, unless you need an insurance referral for treatment (more on that below) or the pain is radiating down one leg. (This can indicate that a nerve is involved.)
Try not to give into bed rest: Gentle activity such as walking is more helpful in the long run. And according to the new guidelines, try massage, heat, acupuncture, and spinal manipulation, or chiropractic.
If you have chronic low back pain (which lasts for more than 12 weeks), the new guidelines found that tai chi, yoga, spine stabilizing exercises recommended by a physical therapist, progressive relaxation, stress reduction, and cognitive behavioral therapy were effective.
Whether you have short- or long-term pain, give one or more of the above strategies between a few days to a week, says Nitin Damle, M.D., president of the ACP. After that, if your pain hasn't begun to ease enough so that you can perform your daily activities, let your doctor know.
He or she can recommend an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) for pain and inflammation for several days.
Here's what's considered appropriate: 800 milligrams of ibuprofen (Advil, Motrin IB, and generic) two to three times a day or 500 mg of naproxen (Aleve and generic) two times a day for five to seven days.
If you're still not finding sufficient relief, Damle says, your doctor can then prescribe a medication such as tramadol (Ultram and generic) or duloxetine (Cymbalta and generic).
But skip acetaminophen (Tylenol and generic); the new research showed no evidence that it improved pain or function.
What nondrug therapy is best? Since no one treatment stood out in the recent studies, pick whichever one is most accessible, enjoyable, and affordable.
Some may be covered by insurance, but you'll have to check with your provider first. And that, say experts, may pose a challenge in getting doctors on board with these new guidelines.
“There are a lot of practical problems with getting patients into these high-value treatments,” says Atlas. “I don’t have a standard referral mechanism for tai chi or yoga or other mind-body therapies. But it’s easy to give a patient a referral to someone who can do an injection.”
Before trying one of these therapies, get the okay from your doctor and ask if he or she can recommend a trusted practitioner or quality instruction. The National Center for Complementary and Integrative Health, or NCCIH, offers tips for choosing a complementary practitioner as well.
In addition, the UCLA Mindful Awareness Research Center offers free online mindfulness and relaxation programs, while the NCCIH website features several easy to follow tai chi videos. (Get information on local tai chi instruction from the American Tai Chi and Qigong Association.)
If you decide to try acupuncture, you can check the National Certification Commission for Acupuncture and Oriental Medicine for practitioners. Look for local licensed massage therapists through the American Massage Therapy Association website. For chiropractic care, make sure anyone you see is licensed.
When it comes to yoga, the NCCIH recommends that you work with an experienced teacher. (The nonprofit Yoga Alliance requires that teachers have at least 200 hours of training for its certification.) If you're looking at classes, apps, or online programs, consider gentle or restorative options.