It began like many other spring mornings on my leafy college campus. Birds were singing outside the dormitory windows, and the sun was shining. As I started to sit up, however, panic hit me: I couldn't get out of bed. Any effort to prop myself up on my elbows or shift my feet and legs met with waves of pain that rolled up my body.
I grabbed my nearby cell phone and called the campus nurse. After a brief chat, she declared that I had thrown out my lower back. The damage had probably been done the day before, when I foolishly lifted a number of large, heavy objects in an empty classroom, too stubborn to find help and too careless to properly bend my knees with each lift. I had nothing to worry about, the nurse informed me. My body would soon heal itself.
Although sudden pain in the lower back can be excruciating, it often feels more irrevocable than it truly is. Some 80 percent of people experience such distress at some point in their lifetime; the vast majority of cases pass without requiring any medical attention. I was lucky—my travail resolved within 24 hours, and aside from a missed class, the incident had no notable repercussions.
That scenario is fairly typical: most cases of lower back pain subside on their own within 12 weeks. For some sufferers, however, the pain becomes chronic, seriously disrupting home and work life.
For most patients, treatment is about helping them manage the pain until it passes. Doctors have over the years prescribed bed rest, pills and, in extreme cases, surgery. Altogether these treatments exact a high cost. The U.S. spends more on lower back and neck pain than almost any other health condition, excepting diabetes and heart disease—topping $87 billion in 2013, according to an analysis of national health records conducted last year.
Researchers have been questioning the costs for a long time, however, and increasingly, the medical community is considering a much simpler solution. Mounting evidence suggests that exercise is among the best remedies because it is able to reduce pain, improve mobility and prevent future discomfort. “[Back pain is] not the only thing that's been overmedicalized,” says back pain specialist Daniel C. Cherkin of the Kaiser Permanente Washington Health Research Institute.* “But it's probably the poster child for how things can go wrong in terms of patient outcomes and cost to society.”
Someday, the research hints, insurance companies could do well to cover special courses of yoga, tai chi or physical therapy as a safer alternative to painkillers and invasive procedures.
Do no Harm
The thinking on how to treat lower back pain has shifted several times in the past few decades. For example, physicians long suspected bed rest would be the ideal way to recuperate. Then a series of studies in the 1980s and 1990s revealed that resting actually slowed recovery.
Doctors also explored surgical options, only to find that these physical fixes were thwarted by the complexity of the lower back. The best candidates for surgery are patients whose pain derives from a specific, identifiable source—such as a tumor or an infection. But 90 percent of cases are untraceable. Insults to the muscles, ligaments, joints, nerves or bones—or some combination thereof—can all cause lower back pain. And the specific sensations are unique to the individual; the same nerve damage in two people can elicit entirely different symptoms. In short, it is hard to know where the pain comes from or how to intervene surgically to make it stop.
In light of the limited efficacy of surgical intervention, doctors have been tackling chronic back pain with pills. Painkillers disrupt the body's efforts to relay nerve signals to the brain, dulling the subsequent discomfort. But here, too, back pain sufferers should be cautious. In three separate large analyses published between 2015 and this year, researchers at the University of Sydney and their colleagues compared evidence from dozens of studies to determine how well various pharmaceutical options assuage back pain and found all the drugs lacking. Acetaminophen, for example, was no more effective than a placebo. Other drugs did provide some relief but came with costs, particularly when used for long periods. Some over-the-counter nonsteroidal anti-inflammatory drugs, such as ibuprofen, can cause stomach ulcers and gastrointestinal bleeding. Prescription opioids, meanwhile, can be addictive and may lead to overdose. “Drugs can be an ally, but they shouldn't be the core of treatment,” says back pain researcher Manuela Ferreira, one of the Sydney scientists who worked on the anti-inflammatory and acetaminophen study.
The fact that opioids are the most commonly prescribed back pain medication has put added pressure on the medical community to find different solutions. To that end, this past February the American College of Physicians released new guidelines on noninvasive treatments for lower back pain. The group's primary message was that pharmaceutical options, and opioids in particular, should be treatments of last resort. In their stead, the authors suggested superficial heat as a well-studied method for relieving acute low back pain. They also found some evidence supporting the use of techniques such as acupuncture and spinal manipulation for acute and chronic pain—although it should be noted that several researchers have questioned whether these treatments are superior to placebo or sham therapies.
For chronic low back pain, the group recommended exercise, rehabilitation therapy, tai chi and yoga, among other approaches. In fact, the authors found exercise to be one of the better studied and supported chronic back pain interventions available. Much of this research focuses on well-rounded fitness regimens, designed by a physical therapist to suit the patient's goals and often incorporating both cardiovascular and strength training.
On Your Feet
In retrospect, researchers should not be surprised that movement is an important part of back pain management. Animal studies throughout the last quarter of the 20th century, in which investigators used a cast to restrict exercise after an injury, have revealed that muscular health and functioning rely on regular use. In other words, muscles need to bear weight, stretch and move to continue supporting the body effectively.
That principle applies equally to chronic and acute low back pain cases, but it may be especially crucial for people whose pain lingers. In 2016 another group of Sydney researchers and their colleagues scoured the available literature and found that exercise was the only treatment approach studied to date that prevented the recurrence of lower back pain. Reviewing the evidence, the team concluded that exercise and education together could cut the risk for another attack of back pain within the year by nearly one half.
Exercise can strengthen the body and back, as well as teach proper posture and lifting techniques. It also offers psychological benefits. The prospect of experiencing pain is frightening to most people; learning how to face that fear and get moving again is part of the healing process, Ferreira notes.
In July a team at the Boston Medical Center and others published findings from a study of 320 chronic lower back pain sufferers who were assigned to yoga, physical therapy or a series of educational reading materials about their condition. For the yoga group, the researchers tailored courses to focus on gentle back stretches such as cat-cow (in which practitioners alternatively round and arch their backs while positioned on all fours) and child's pose (in which the body faces the floor in a modified fetal position). The physical therapy intervention included one-on-one coaching, instructions for at-home exercise and aerobic workout sessions. After three months, the yoga and physical therapy groups were significantly less likely to use pain medication to deal with their discomfort than people who simply received educational material. Overall, the team found yoga to be just as effective as physical therapy; both options reduced pain and improved mobility. In addition, the researchers followed up with participants who continued their exercises (either at home or with an instructor or therapist) for a full year and found these benefits persisted.
Trial and Error
One important caveat: no one solution for chronic low back pain works well for everyone. Instead most treatments studied—whether pills, push-ups or acupuncture—help some people cope with their pain but fail to help others.
That conclusion may sound discouraging, but in practice, it means that most individuals will need to try a few options to find a treatment that works well. As a solution, exercise excites many therapists and physicians because it can provide relief and boost mobility with few side effects at comparatively low cost, all while improving overall quality of life.
As to which form of exercise to try first, there are not enough head-to-head comparisons to pick a winner, nor is there consensus on whether a specific form of exercise is a bad choice, per se. The lower back is so central to the body that even adding a daily walk through the park can give the region a needed workout.
Sydney's Chris Maher, who is an author on the exercise and drug studies, suspects that the particular kind of exercise you end up choosing may be much less important to solving the problem than simply finding a way to be more active. “The best form of exercise,” he asserts, “is the one you're going to stick with.”
*Editor’s Note (11/3/17) This sentence from the article that appeared in the print edition was edited after posting to correct an affiliation.