Editing Back pain (section)

=== Nonspecific pain ===
Patients with uncomplicated back pain should be encouraged to remain active and to return to normal activities.

The [[Pain management|management]] goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible, to restore the individual's ability to function in everyday activities, to help the patient cope with residual pain, to assess for side effects of therapy and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain at a manageable level to progress with rehabilitation, which then can lead to long-term pain relief. Also, for some people the goal is to use nonsurgical therapies to manage the pain and avoid major surgery, while for others surgery may represent the quickest path to pain relief.<ref>{{cite journal | vauthors = Baron R, Binder A, Attal N, Casale R, Dickenson AH, Treede RD | title = Neuropathic low back pain in clinical practice | journal = European Journal of Pain | volume = 20 | issue = 6 | pages = 861–73 | date = July 2016 | pmid = 26935254 | pmc = 5069616 | doi = 10.1002/ejp.838 }}</ref>

Not all treatments work for all conditions or for all individuals with the same condition, and many must try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1–10%) require surgery.<ref>{{Cite web|url=https://www.health.harvard.edu/pain/when-is-back-surgery-the-right-choice|title=When is back surgery the right choice? | publisher = Harvard Health Publishing |date=13 June 2014|access-date=2019-12-24}}</ref>

====Conservative Care====
Back pain is generally first treated with nonpharmacological therapy, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture and spinal manipulation therapy may be recommended.<ref name=":0">{{cite journal | vauthors = Stockwell S | title = New Clinical Guideline for Low Back Pain Says Try Nondrug Therapies First | language = en | journal = The American Journal of Nursing | volume = 117 | issue = 5 | page = 16 | date = May 2017 | pmid = 28448354 | doi = 10.1097/01.naj.0000516263.01592.38 |doi-access=free | s2cid = 40086812 }}</ref> There is poor evidence for the effectiveness of most interventional treatments (drugs and surgery) for back pain and hence non-interventional treatments should be prioritized in the vast majority of cases.<ref>{{cite journal |last1=Orchard |first1=John |title=The fight between medicine and scepticism needs to be resolved by evidence: Book reviews |journal=JSAMS Plus |date=2023 |volume=2 |pages=100042 |doi=10.1016/j.jsampl.2023.100042|doi-access=free }}</ref><ref>{{cite book |last1=Mannix |first1=Liam |title=Back up: why back pain treatments aren't working and the new science offering hope |date=2023 |publisher=NewSouth Publishing |location=Sydney, N.S.W |isbn=9781742238081}}</ref>
* [[Heat therapy]] is useful for back [[spasm]]s or other conditions. A review concluded that heat therapy can reduce symptoms of acute and subacute low-back pain.<ref name="pmid16641776">{{cite journal | vauthors = French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ | title = A Cochrane review of superficial heat or cold for low back pain | journal = Spine | volume = 31 | issue = 9 | pages = 998–1006 | date = April 2006 | pmid = 16641776 | doi = 10.1097/01.brs.0000214881.10814.64 | s2cid = 9349942 }}</ref>
* Regular activity and gentle stretching exercises is encouraged in uncomplicated back pain and is associated with better long-term outcomes.<ref name=":8">{{Cite book|title=Rosen's emergency medicine : concepts and clinical practice| vauthors = Walls RM, Hockberger RS, Gausche-Hill M |isbn=978-0323354790|edition=Ninth|publisher=Elsevier|location=Philadelphia, Pennsylvania|oclc=989157341 |date=2017}}</ref><ref>{{cite journal | vauthors = Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB | title = Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD007612 | date = June 2010 | pmid = 20556780 | doi = 10.1002/14651858.CD007612.pub2 |doi-access=free}}</ref> Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended.<ref name=":2">{{Cite book|title=Wall and Melzack's textbook of pain|date=2013|publisher=Elsevier/Saunders| veditors = McMahon SB |isbn=978-0702040597|edition=6th|location=Philadelphia, Pennsylvania|oclc=841325533|page= }}{{page needed|date=February 2021}}</ref> These exercises are associated with better patient satisfaction, although they have not been shown to provide functional improvement.<ref name=":8" /> However, one review found that exercise is effective for chronic back pain but not for acute pain.<ref name="pmid16034851"/> Exercise should be performed under the supervision of a healthcare professional.<ref name="pmid16034851">{{cite journal | vauthors = Hayden JA, van Tulder MW, Malmivaara A, Koes BW | title = Exercise therapy for treatment of non-specific low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD000335 | date = July 2005 | volume = 2011 | pmid = 16034851 | doi = 10.1002/14651858.CD000335.pub2 | pmc = 10068907 |doi-access=free}}</ref> Supervised walking programs have been shown to be cost-effective at reducing back pain recurrences.<ref>{{cite journal |last1=Pocovi |first1=Natasha C |last2=Lin |first2=Chung-Wei Christine |last3=French |first3=Simon D |last4=Graham |first4=Petra L |last5=van Dongen |first5=Johanna M |last6=Latimer |first6=Jane |last7=Merom |first7=Dafna |last8=Tiedemann |first8=Anne |last9=Maher |first9=Christopher G |last10=Clavisi |first10=Ornella |last11=Tong |first11=Shuk Yin Kate |last12=Hancock |first12=Mark J |title=Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial |journal=The Lancet |date=June 2024 |volume=404 |issue=10448 |pages=134–144 |doi=10.1016/S0140-6736(24)00755-4|doi-access=free |pmid=38908392 }}</ref>
* [[Massage therapy]] may provide short-term pain relief, but not functional improvement, for those with acute lower back pain.<ref name="Furlan20152">{{cite journal | vauthors = Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M | title = Massage for low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD001929 | date = September 2015 | volume = 2015 | pmid = 26329399 | doi = 10.1002/14651858.CD001929.pub3 | pmc = 8734598 |doi-access=free}}</ref> It may also offer short-term pain relief and functional improvement for those with long-term (chronic) and subacute lower pack pain, but this benefit does not appear to be sustained after six months of treatment.<ref name="Furlan20152" /> There do not appear to be any serious adverse effects associated with massage.<ref name="Furlan20152" />
* [[Acupuncture]] may provide some relief for back pain. However, further research with stronger evidence is needed.<ref>{{cite journal | vauthors = Yeganeh M, Baradaran HR, Qorbani M, Moradi Y, Dastgiri S | title = The effectiveness of acupuncture, acupressure and chiropractic interventions on treatment of chronic nonspecific low back pain in Iran: A systematic review and meta-analysis | journal = Complementary Therapies in Clinical Practice | volume = 27 | pages = 11–18 | date = May 2017 | pmid = 28438274 | doi = 10.1016/j.ctcp.2016.11.012 | url = https://www.clinicalkey.com/#!/content/journal/1-s2.0-S1744388116302006 }}</ref>
* [[Spinal manipulation]] appears to provide similar effects to other recommended treatments for chronic low back pain.<ref>{{cite journal | vauthors = Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW | title = Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials | journal = BMJ | volume = 364 | pages = l689 | date = March 2019 | pmid = 30867144 | pmc = 6396088 | doi = 10.1136/bmj.l689 }}</ref> There is no evidence it is more effective than other therapies or sham, or as an adjunct to other treatments, for acute low back pain<ref>{{cite journal | vauthors = Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for acute low-back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 9 | pages = CD008880 | date = September 2012 | pmid = 22972127 | pmc = 6885055 | doi = 10.1002/14651858.CD008880.pub2 | collaboration = Cochrane Back and Neck Group }}</ref>
* "Back school" is an intervention that consists of both education and physical exercises.<ref name=":7" /><ref name=":15">{{cite journal | vauthors = Parreira P, Heymans MW, van Tulder MW, Esmail R, Koes BW, Poquet N, Lin CC, Maher CG | display-authors = 6 | title = Back Schools for chronic non-specific low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD011674 | date = August 2017 | issue = 8 | pmid = 28770974 | pmc = 6483296 | doi = 10.1002/14651858.CD011674.pub2 }}</ref> There is no strong evidence supporting the use of back school for treating acute, subacute, or chronic non-specific back pain.<ref name=":7">{{cite journal | vauthors = Poquet N, Lin CW, Heymans MW, van Tulder MW, Esmail R, Koes BW, Maher CG | title = Back schools for acute and subacute non-specific low-back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD008325 | date = April 2016 | issue = 4 | pmid = 27113258 | doi = 10.1002/14651858.CD008325.pub2 |doi-access=free| pmc = 11074243 }}</ref><ref name=":15" />
* [[Shoe insert|Insoles]] appear to be an ineffective treatment intervention.<ref>{{cite journal | vauthors = Sahar T, Cohen MJ, Ne'eman V, Kandel L, Odebiyi DO, Lev I, Brezis M, Lahad A | display-authors = 6 | title = Insoles for prevention and treatment of back pain | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005275 | date = October 2007 | pmid = 17943845 | doi = 10.1002/14651858.cd005275.pub2 |doi-access=free}}</ref>
* While [[Traction (orthopedics)|traction]] for back pain is often used in combination with other approaches, there appears to be little or no impact on pain intensity, functional status, global improvement or return to work.<ref>{{cite journal | vauthors = Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de Vet HC, Brønfort G, Bouter LM, van der Heijden GJ | display-authors = 6 | title = Traction for low-back pain with or without sciatica | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD003010 | date = August 2013 | volume = 2013 | pmid = 23959683 | pmc = 6823219 | doi = 10.1002/14651858.cd003010.pub5 }}</ref>

====Medication====
If nonpharmacological measures are ineffective, medication may be administered. However, caution should be undertaken with medications as long-term results of painkiller usage are worse than short-term.
* [[Nonsteroidal anti-inflammatory drug|Non-steroidal anti-inflammatory drugs (NSAIDs)]] are typically attempted first.<ref name=":0" /> NSAIDs have been proven more effective than placebo, and are usually more effective than [[Paracetamol|paracetamol (acetaminophen)]].<ref name="pmid18646078">{{cite journal | vauthors = Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P | title = Injection therapy for subacute and chronic low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD001824 | date = July 2008 | volume = 2008 | pmid = 18646078 | doi = 10.1002/14651858.CD001824.pub3 | pmc = 7096223 }}</ref>
* Long-term use of [[opioid]]s has not been properly tested to determine efficacy for treating chronic lower back pain.<ref name=":1">{{Cite encyclopedia|url=https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323354790000477|encyclopedia=Rosen's Emergency Medicine: Concepts and Clinical Practice|title=Musculoskeletal Back Pain| vauthors = Sudhir A, Perina D |publisher=Elsevier|year=2018|isbn=978-0323354790|via=ClinicalKey|pages=569–76}}</ref><ref name=":3" /> For severe back pain not relieved by NSAIDs or acetaminophen, opioids are sometimes used.<ref>{{cite journal | vauthors = Deyo RA, Von Korff M, Duhrkoop D | title = Opioids for low back pain | journal = BMJ | volume = 350 | pages = g6380 | date = January 2015 | pmid = 25561513 | pmc = 6882374 | doi = 10.1136/bmj.g6380 }}</ref> However, they do not appear to be more effective than placebo.<ref>{{cite journal |last1=Jones |first1=CMP |last2=Day |first2=RO |last3=Koes |first3=BW |last4=Latimer |first4=J |last5=Maher |first5=CG |last6=McLachlan |first6=AJ |last7=Billot |first7=L |last8=Shan |first8=S |last9=Lin |first9=CC |last10=OPAL Investigators |first10=Coordinators |title=Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. |journal=Lancet |date=22 July 2023 |volume=402 |issue=10398 |pages=304–312 |doi=10.1016/S0140-6736(23)00404-X |pmid=37392748|url=https://findresearcher.sdu.dk/ws/files/256315722/OPAL_manuscript_FINAL.pdf }}</ref> Opioids may not be better than NSAIDs or antidepressants for chronic back pain with regard to pain relief and gain of function.<ref name=":3">{{cite journal | vauthors = Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC | title = Opioids compared to placebo or other treatments for chronic low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD004959 | date = August 2013 | volume = 2014 | pmid = 23983011 | doi = 10.1002/14651858.CD004959.pub4 | doi-access = free | pmc = 11056234 }}</ref> It is almost certain that over-prescription of opiates for conditions like back pain has been as a result of excess pharmaceutical company marketing rather than evidence of benefit, and many thousands of deaths have resulted.<ref>{{cite book |last1=Radden Keefe |first1=Patrick |title=Empire Of Pain: The Secret History Of The Sackler Dynasty |date=2021 |publisher=Doubleday |isbn=9781529063073 |pages=560}}</ref> Back pain is considered one of the key conditions where opiate painkillers have been over-prescribed leading to the [[Opioid epidemic]].
* [[Muscle relaxant|Skeletal muscle relaxers]] may also be used.<ref name=":0" /> Their short-term use has been proven effective in the relief of acute back pain.<ref name="pmid12804507">{{cite journal | vauthors = van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM | title = Muscle relaxants for non-specific low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 2 | page = CD004252 | year = 2003 | volume = 2017 | pmid = 12804507 | pmc = 6464310 | doi = 10.1002/14651858.CD004252 }}</ref> However, the evidence of this effect has been disputed, and these medications do have negative side effects.<ref name=":1" />
* For patients with nerve root pain and acute radiculopathy, there is evidence that a single dose of steroids, such as [[dexamethasone]], may provide pain relief.<ref name=":8"/>
* [[Epidural steroid injection|Epidural corticosteroid injection]] (ESI) is a procedure in which steroid medications are injected into the [[epidural space]]. The steroid medications reduce inflammation and thus decrease pain and improve function.<ref>{{Cite book|title=Campbell's operative orthopaedics| vauthors = Azar FM, Canale ST, Beaty JH, Campbell WC |isbn=978-0323374620|edition=Thirteenth|publisher=Elsevier|location=Philadelphia, Pennsylvania|oclc=962333989 |year=2016}}</ref> ESI has long been used to both diagnose and treat back pain, although recent evidence, including a 2025 clinical practice guideline published in BMJ,<ref>{{cite journal |title=Spinal interventions for chronic back pain |journal=BMJ |date=2025 |volume=388 |page=r179 |doi=10.1136/bmj.r179 |last1=Ballantyne |first1=Jane C. |pmid=39971342 }}</ref> recommends against the use of ESI for '''chronic''' back pain due to a lack of efficacy.<ref>{{Cite book|title=Bradley's neurology in clinical practice| vauthors = Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, Bradley WG |isbn=978-0323287838|edition=Seventh|publisher=Elsevier|location=London|oclc=932031625|date=2015|page=}}{{page needed|date=February 2021}}</ref>