By Joe Fleming

Ditch the pills. That’s what updated clinical guidelines[1] from the American College of Physicians revealed in early 2017. It’s so easy to head straight for the medicine cabinet when a twinge in your lower back has you howling, but a comprehensive review of randomized, controlled trials and systematic reviews on back pain relief is recommending clinicians encourage patients up nonpharmacological routes instead.


Why nonpharmacological treatments?

Regardless of treatment, most acute or subacute low back pain has actually been shown to diminish over time. The risks of popping over-the-counter pain relievers or even prescribed opiates far outweighs the risks of simply letting your back heal on its own.

Expediting the healing process, however, and obtaining relief from pain, enhancing your overall day-to-day functionality, and being able to return to work (if low back pain has prevented you) is possible with noninvasive practices. Surprising to some, the American College of Physicians first recommendation includes heat therapy, massage, acupuncture, and spinal manipulation. If medicinal aids truly are needed, skeletal muscle relaxants or nonsteroidal anti-inflammatories should be administered.


How do those treatments work?

Acute or subacute back pain is typically the result of overused, strained or inflamed muscles. Heat therapy is the simple application of hot packs, warm compress or heating pads to the affected area of your back (a warm bath counts too). Heat therapy helps relax swollen muscles, boost blood flow to the affected area, and eliminate lactic acid waste buildup which, in turn, relieves pain. Unless otherwise indicated by your doctor, heat should be applied for up to 20 minutes at a time, around three times a day.


Massage combines the power of tactile sense with targeted pressure, rubbing, and muscle manipulation to relieve low back pain. A 2011 study[2] found that participants who received one hour weekly massages over 10 weeks experienced low back pain reduction, a boost in functionality, and a reduction in the amount of anti-inflammatories they were taking. Massage therapy should be conducted by a trained and licensed therapist who knows the proper muscle groups to target and manipulate to alleviate back pain.

Acupuncture, while hotly debated at the turn of the century, has picked up steam as a short-term pain reliever for back pain sufferers. This ancient Chinese practiced involves super thin needles being inserted into the body’s skin and tissues at key points (meridians) which affect your body’s natural flow of energy (qi). Researchers believe the practice in fact stimulates a nervous system response which turns on opioid receptors and results in an analgesic effect.


Spinal manipulation which involves jolting and moving joints, massage, and applied pressure can help reduce inflammation, relieve pressure on joints, and improve nerve function. When used in combination with exercise, a 2015 randomized clinical trial[3] found that manual-thrust spinal manipulation reduced acute and subacute low back pain at up to 4 weeks of treatment.


What If My Back Pain is Chronic, Not Just Acute?

Treatment of chronic low back pain goes a step further with the ACP recommending more physical activity as treatment[4] – exercise, yoga, tai chi, multidisciplinary rehabilitation, motor control exercise, and progressive relaxation, for example. Regular physical fitness when completed daily for at least 30 minutes helps increase blood circulation, reduce muscle inflammation, loosen stiff joints, and boost feel-good endorphins.

Mindfulness activities including yoga practice and tai chi weave in meditation, deep breathing, and relaxation techniques to foster positive feelings of self-awareness and peace, also helping relieve stress and anxiety which might be amplifying back pain. Additional treatment incorporating spinal manipulation, biofeedback, and behavior therapy are also in the guidelines for treating chronic low back pain.


What Happens When None of Those Treatments Work?

Inadequate response to nonpharmacological treatments can be frustrating and stressful for both patient and treating clinician. With opioids having a high risk for abuse and addiction, the ACP recommends them as the last, last choice in treating chronic back pain.


Instead, NSAIDS (nonsteroidal anti-inflammatories) like aspirin and ibuprofen can be helpful pharmacological aids when taken in the directed doses. On a chemical level, NSAIDS actually block an enzyme in the body which produces compounds that lead to swelling and inflammation. Acetaminophen, commonly known in the US as Tylenol, is not an NSAID and is not recommended in efforts of reducing painful back muscle inflammation.


It is important to note that the updated guidelines do not address topical therapies (i.e. arnica or capsaicin cream), injection therapies, or the benefits of wearing a back brace for lower back pain. As pain is defined as electrical signals sent from your nerves to your brain, the noninvasive and nonmedicinal treatments that work for you may vary from those that work for the next patient. Treatment that works for you without creating unhealthy behaviors like overeating or not exercising, and with low risk to your organ health (i.e. your heart, brain, and kidneys) is always a good place to start.

About the author:  Joe Fleming is the President at Interested in all things related to living a healthy lifestyle, he enjoys sharing and expressing his passion through writing. Working to motivate others and defeat aging stereotypes, Joe uses his writing to help all people overcome the obstacles of life. Covering topics that range from physical health, wellness, and aging all the way to social, news, and inspirational pieces…the goal is help others “rebel against age”.


[1] Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians Annals of Internal Medicine. 2017;166(7):514-530.

[2] Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low-back pain: a randomized, controlled trial. (link is external)Annals of Internal Medicine. 2011;155(1):1–9.


[3] SchneiderMHaasMGlickRStevansJLandsittelDComparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial.Spine (Phila Pa 1976)20154020917

[4] ChouRHuffmanLHAmerican Pain SocietyNonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.Ann Intern Med2007147492504