Dos and don'ts: The expert guide to managing your back pain

Lingering back pain is expensive to treat. It's also difficult to treat effectively. Here's our guide to managing the nagging ache 

Here’s what you should (and should not) do for your back pain

Back pain accounts for 25% of annual GP visits in Ireland, according to research at the University of Limerick. It is one of the most costly conditions to diagnose and treat, with the Irish Pain Society estimating that chronic pain [which includes back pain] costs the Irish economy €4.7bn a year.

A glimmer of hope for lower back pain sufferers was raised recently with news of a drug that experts have billed as a “gamechanger” for some forms of the condition.

Early trials of the PP353 drug, developed by Persica Pharmaceuticals in Britain, have had promising results for people with back pain caused by an infection rather than by muscular or spinal issues. A combination of three widely available medicines — an antibiotic, called linezolid; a dye, called iohexol; and a thermosensitive gel — the drug is injected into the lower back to reduce infection around the spinal discs. Six out of ten people taking part in one of the trials had significantly reduced pain.

However, Professor Dominic Hegarty, a consultant in pain management at the Orthopaedic and Spine Centre, Mater Private Hospital, Cork, said it is not yet clear whether some forms of back pain are caused by infection, so there is no firm evidence that this sort of medication will help many people. And, there is no magic bullet for back pain. 

“Even if this new drug becomes available, it is not something you would get over the counter,” Hegarty said. “It involves a high-risk injection with a fairly aggressive antibiotic, so would not be prescribed lightly.”

When you are suffering from a bad back, it is tempting to give everything a try — from popping painkillers to booking an acupuncture session.

Another recent study found that the most common treatments do little to relieve lower back pain. According to a scientist at the University of New South Wales, reporting in BMJ Evidence Based Medicine, of the range of non-surgical and non-interventional treatments reviewed — including reflexology, taping, manual therapies, such as osteopathy and massage, and painkillers and exercise — only 10% worked.

“Most provided pain relief that was only marginally better than placebo,” said Dr Aidan Cashin, deputy director of the Centre for Pain IMPACT at Neuroscience Research Australia (NeuRA) and senior lecturer in the School of Health Sciences, who led the study. “In other words, our review did not find reliable evidence of large effects for any of the included treatments.”

Dr Sean Molloy, an Irish consultant orthopaedic spinal surgeon, who works at HCA The Princess Grace Hospital, London, said that low back pain is widespread, often self-limiting, and usually improves within a few weeks.

“Some tears can take up to six weeks to heal,” Molloy said. “But many people find their condition gets better within as little as two to three weeks.”

Ultimately, no two people respond in the same way to any back pain treatments or therapies, and it is a case of talking to a medical professional to find what works best for you. “Anything you have tried in the past that has helped will likely work again,” Molloy said.

The biggest changes you can make to strengthen your back are lifestyle ones. “Good back hygiene, in the form of a healthy diet, adequate activity and sleep, are the most important steps we can all take to protect our backs,” Hegarty said.

Here’s what you should (and should not) do:

Will manual therapy be helpful?

Molloy, who is also a chiropractor, said that manual therapies, which also include massage, can be beneficial.

“In some cases, they are useful in correcting and improving mechanical issues of the back,” he said.

Medical guidelines also suggest that acupuncture might be helpful for people with back pain that lasts more than 12 weeks. It’s best to seek an acupuncture-trained physiotherapist, who offers it as part of a wider recovery and pain-management programme.

Should I stop exercising to ease my back pain?

In the recent Australian study, exercise was shown to be ineffective in easing acute back pain. Molloy advised against taking up any new form of exercise — particularly the high-impact variety, such as running or activities involving jumping — as it can worsen the problem. “With acute back pain, there is often a tear in the area surrounding the discs, and that can lead to muscle spasms,” Molloy said.

“There’s a chance that exercising could exacerbate these spasms and cause more pain.”

It’s a different story with chronic back pain, defined as pain that lasts more than 12 weeks. Activities like walking, swimming and stretching can help ease chronic back pain. Cashin’s team reported that exercise helped relieve chronic pain, albeit slightly more than a placebo tablet.

“Doing too much of any type of exercise might not be good for your back, so, if unsure, check with a medical professional before trying something,” Hegarty said.

Will cardio activity help to keep my back healthy?

In a 2020 review published in the British Journal of Sports Medicine, Daniel Belavy, an associate professor at the Institute for Physical Activity and Nutrition at Deakin University in Australia, looked at how specific types of exercise might help to relieve chronic back pain.

He suggested that any activity that “improves the efficiency and capacity of your cardio-respiratory system” can be helpful.

This includes cycling, jogging, and swimming, although the activity needs to be graded, and you should start with just a few minutes of each exercise.

A Lancet study of people aged 20 to 82, all of whom had experienced lower back pain at some point, found that those who followed a tailored walking programme of an average of 130 minutes a week, or 26 minutes of walking on five allotted days, lasted nearly twice as long without a recurrence of their pain as those who didn’t take up extra walking.

Should I also work at strengthening my core muscles?

“Strengthening the core muscles, those that wrap around the spine to support good posture, can help to keep back pain at bay,” said Molloy. “Any exercise approach that encourages this might be helpful.”

In his review of different types of exercise and their effects on back pain, Belavy found that Pilates was useful, but no more so than other types of core work, such as general stabilisation and strengthening exercises that target the trunk muscles. And, Belavy stressed, core exercise also didn’t have much effect on chronic low back pain, if performed in isolation — you need general fitness, too.

In other words, a strong core is not a magic bullet for back-pain prevention, but it might help.

Can I resort to taking painkillers?

“We found, for acute low back pain, NSAIDs [non-steroidal anti-inflammatory drugs] may be effective,” Cashin said of his findings. Acute or severe back pain might benefit from painkillers or medicines to relax the muscles in your back, such as NSAIDS, including ibuprofen.

Don’t bother with paracetamol on its own, which is ineffective according to the new study. “It can be taken in combination with other painkillers on the advice of your GP or pharmacist,” Molloy said.

No painkillers should become a long-term crutch. Cashin and his team reported that steroid injections were not likely to be effective for acute back pain, while anaesthetics and antibiotics didn’t work for chronic low back pain.

Do antidepressants work for chronic back pain?

Prescribing antidepressants was once commonplace for low back pain, but Cashin found that they weren’t helpful for people with chronic low back pain. Molloy said the prescribing of antidepressants for back pain is now discouraged.

How antidepressants might work, he said, is “not by improving mood, but by lowering neuropathic pain associated with some forms of back pain, such as cases of sciatica that cause pain in the legs as well as the lower back”.

However, he added: “I would not consider them as a first-line treatment, as there is insufficient evidence that they help most cases of back pain.”