Research found acetaminophen did no better than a placebo in reducing low back pain. But it noted that physical therapy, massage and acupuncture may help.

One of the best prescriptions for treating low back pain may not be a pill. Steven Atlas, MD, MPH, of Massachusetts General Hospital, gives his patients a note to take to work: Get out of your office chair every 20 to 30 minutes and walk around to loosen up your back.

The physicians’ group discouraged reliance on many of the medications often used to treat low back pain.

Dr. Atlas’s advice is in line with new recommendations from the American College of Physicians. He calls the recommendations a major change and penned an accompanying editorial in the Annals of Internal Medicine. The group advises that treatment such as physical therapy, chiropractic care and exercise be used earlier and more often than pills.

Medication Impact

The physicians’ group discouraged reliance on many of the medications often used to treat low back pain. Acetaminophen, a safe and cheap over-the-counter medicine, is not recommended anymore. Research found it did no better than a placebo (a pill with no medicine in it) in treating low back pain. Acetaminophen had been favored because it is well-tolerated, especially by older patients.

Nonsteroidal anti-inflammatory (NSAID) pills, like aspirin, ibuprofen or naproxen, were noted as OK for low back pain that lasts up to a few weeks, but have not been studied for long-term use. Muscle relaxants may be used as an alternative, especially for pain that prevents sleep, but steroid pills have not been shown to be helpful, the group said.

Steven Atlas, MD, MPH
Steven Atlas, MD, MPH

And opioids were suggested as a treatment for both short-term and chronic low back pain, only as a last option.

Helping the Body Heal Itself

Up to 80 percent of the population will have an episode of back pain during their lives, Dr. Atlas says. Most back pain is caused by muscle spasms and strained ligaments. Another contributor is arthritis.

“Even if you have severe pain, it doesn’t, in most cases, indicate a serious condition,” Dr. Atlas says. “Sometimes, people have the feeling like ‘I can’t do anything unless I have no pain.’ But there’s good evidence that staying in bed for a long time will actually delay your recovery.”

He tells patients to continue their activities as well as they can, even if they are in pain. Walking, swimming and biking do not overly strain the back and can be done during pain episodes, he says. They also can help with prevention.

“There’s good evidence that staying in bed for a long time will actually delay your recovery.”

Dr. Atlas advises patients to select exercises they enjoy. When he has back pain, he runs. It doesn’t relieve his pain, but it makes him happy and helps him get through the episode.

Starting Point for Lifestyle Changes

He encourages patients to talk with their doctor about physical therapy, chiropractic care, massage, yoga, tai chi, meditation and complementary treatments. In research, all have been shown to provide modest benefits. Mass General offers referrals to its Benson-Henry Institute for Mind Body Medicine and physical therapy at multiple Mass General and Spaulding Rehabilitation sites. Because some of these services fall outside of traditional medicine, patients may need guidance from doctors on finding and evaluating local resources. Cost and insurance coverage vary and can affect the choices patients make.

Like medications, these physical treatments are not a total cure for pain.

“They’re not homeruns. They provide modest relief,” Dr. Atlas says. He says more research is needed to determine what combinations of physical treatments work best.

He suggests using back pain as a starting point for lifestyle changes. “Back pain usually reflects that we are not taking care of ourselves enough,” he says. “We’re overweight. We’re not exercising. Our back tells us to pay attention to it by saying it hurts.”

To support the patient care of Dr. Atlas and other Mass General doctors, please contact us.

Low back pain recommendations:

  1. Try heating packs on the area that hurts.
  2. Modify activity if you are in extreme pain. If not, continue with reasonable exercise.
  3. Avoid prolonged sitting. Stand and walk around every 20 to 30 minutes.
  4. Try physical therapy, massage, chiropractic care, meditation or acupuncture.
  5. Understand once you have back pain it may return, but prevention can work to decrease the frequency and severity of episodes.
  6. Work with your doctor to understand if and when medication might be useful. For example, if you can’t sleep.

See a doctor for low back pain if:

  • the pain is so severe you can’t continue daily activities
  • the pain radiates down your leg
  • you also have difficulty urinating or abdominal pain
  • you are being treated for cancer or a disease where new pain is a concern
  • episodes become more frequent