What's the best way to treat lower back pain? Here's what the science says.

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Dear Julia: I've heard lower back pain is mostly mysterious and there's little doctors can do to help. Is that true? What do we know about back pain?

Dear reader: I studied anthropology in grad school, and one of the common aphorisms people would throw around was that cooking made us human — it's what brought people from nature to culture.

The more I read about low back pain, the more I question that. I think there's a case to be made that back pain is actually what makes us human.

We're the only mammals who suffer from back pain, and some anthropologists, like Case Western's Bruce Latimer, think that tinkering with our backs over the course of evolution — to get us standing upright on two feet — brought with it inevitable pain. "To balance and stand up, we had to create a hollow in our lower back, above the butt. That’s a balancing mechanism," Latimer told me. "But what it did was cause all kinds of problems."

(Alila Medical Media/Shutterstock)

Lower back pain is nearly universal. It's one of the top reasons people go to see their doctors in the US, and the leading reason for missing work anywhere in the world. Obesity, being overweight, smoking, depression, and anxiety have all been linked with lower back pain. But almost everyone, everywhere, suffers from back pain at some point in their lives, in both rich and poor countries.

It afflicts the young and the old, those who work in the knowledge economy and those who work with their hands, the hyper-educated and the uneducated, the very fit and the unfit. Many people think of lower back pain as a side effect of today's sedentary lifestyle, but it may just be that we've medicalized an age-old problem.

Maybe this is why we haven't yet cured low back pain. There's little you can do to prevent it, beyond what you should be doing for your body anyway: getting a reasonable amount of exercise, maintaining a healthy weight, and avoiding injury. There are a range of treatments that can only sort of help (more on that below) and definitely no magic pill or cure.

What causes lower back pain?

Doctors talk about back pain in a few different ways, but the kind most people suffer from is what they call "nonspecific low back pain." That's what I've been referring to here, and it has no detectable cause — like a tumor, pinched nerves, osteoporosis, or a fracture. It can be acute (lasting up to four weeks), subacute (lasting between four and 12 weeks), or chronic (lasting more than 12 or more weeks). But rarely, back pain is a sign of a more serious medical problem.

If you don't accept the evolutionary theory that Latimer described — that back pain is an inevitable part of human evolution — the causes of lower back pain are indeed mostly mysterious, some mix of genetic, physical, psychological, environmental, and social factors.

"Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role, but psychological and social factors also play a big role," said Roger Chou, a back pain expert and professor at Oregon Health and Science University. "For example, given the same imaging findings, we know that people who are depressed or are highly unsatisfied with their jobs tend to have worse back pain than people without these factors." Partly for this reason, doctors don't recommend doing imaging studies (like MRIs) for acute episodes of low back pain; it can lead to overtreatment — like surgery — that won't improve health outcomes.

What helps alleviate back pain?

There are several things doctors now think you shouldn't do for lower back pain. Taking antidepressants doesn't necessarily help any more than an inactive pill (placebo), and the drugs cause side effects. Bed rest isn't necessary. Surgery and steroid injections are probably overtreating the problem, and should be avoided. So should opioids, because the serious side effects, like accidental overdose and addiction, don't usually outweigh the benefits. Over-the-counter pain medications like acetaminophen (i.e., Tylenol) are also increasingly seen as unhelpful.

There are a range of things that can help, however. Systematic reviews of scientific studies have shown that exercise generally improves symptoms, particularly supervised programs with physiotherapists. Pilates and yoga have been shown to work — but not any more than other forms of exercise. Acupuncture and massage also seem to alleviate pain.

None of these are particularly outstanding solutions — not even chiropractic treatment, which often involves spinal manipulation. Although this one is among the most popular therapies for lower back pain, the evidence suggests it doesn't actually doesn't work any better than all the other therapies and activities described above. As Murdoch University's Bruce Walker told me, his systematic review found "there were very similar but small improvements with chiropractic treatment compared to other treatments." And other studies have found the same.

Roger Chou summed it up this way: "In general, for chronic low back pain there are a number of treatments that look like they can help." So he suggested exercise as the first-line therapy, and doing it under the supervision of a physiotherapist if possible. (Home exercise is probably just as helpful for back pain but there's less research on it, so we know less about the effect it has, and it may be harder to stay motivated.) "We don’t know the best type of exercise — most studies show effects are similar for different types of exercise — so the most important things seem to be some kind of movement and activity, and finding something that you like and can stick with," he said.

This may be a frustratingly vague answer, but maybe it's also liberating: With no magic pill, just try some exercises, and then maybe other therapies like massage, and find the ones you like. And do it soon. After all, you're human, which means you will probably suffer back pain at some point — if you haven't already.

Send your questions to Julia via the submission form or@juliaoftoronto on Twitter. Read more about Dear Julia here.

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