In studies, those who resumed normal, non-strenuous activities recovered sooner than did those who rested in bed or people who did more intense back strengthening exercises right away.

Experts recommend that back pain-sufferers resume light daily activities as soon as possible. Exercise such as walking typically can be resumed after the first day or two. People with intolerable symptoms may need to take it easier for longer but bed rest is discouraged, in general, for longer than 1-2 days.

Individuals with low back pain used to be treated with bed rest. However, studies have shown that people who went back to ordinary activities recovered sooner than those who rested in bed or who did vigorous back strengthening exercises.

All well-designed studies addressing this issue have reached similar conclusions: that people with low back pain who remain active and involved in ordinary, light activities:

• Experience less long-term disability
• Return to work faster
• Require fewer health care visits, tests, and procedures

None of the studies found that bed rest improved the chance of recovery. None of the studies found that early return to light activities had any harmful effects.

Ninety per cent of people with back pain recover in a few weeks. Most recover within two weeks. Half have recurring pain in the next year. Studies have suggested that the best means of avoiding future episodes is to use proper lifting techniques, maintain a healthy weight, and stop smoking. Classes in back care have been very helpful for prevention of future problems.

A well-designed five year study of more than 500 back pain sufferers looked at education and reassurance that ordinary, light activity is safe and improves the chance of recovery (Klenerman, Slade; 1995). The study found that people who received this information were much more likely to recover and return to a normal lifestyle than people who did not receive education.

Patients in the study who received education were told that:

• Their low back pain may be caused by a crack in a disc ("cushion") that sits between the bones of the spine that can lead to irritation and swelling;
• The irritation causes spasm (tightening) and stiffness in the nearby muscles that support the back. The tension and high pressure can decrease the flow of blood to these muscles which causes more pain;
• The pain due to muscle spasm causes the back to tense even more, creating a cycle which further increases pain;
• Fear also causes the back muscles to tense even more, which maintains the cycle of increased spasm, pain, and decreased blood flow to muscles;
• The worst thing that a person with back pain can do is to be too cautious and, as a result, tense up his or her back

To improve their condition, people were told:

• That light activity would not worsen their condition and would not further injure the disc ("cushion"). Instead activity could relax the muscles, improve blood flow which helps with healing;
• To walk as normally and as flexibly as possible (without tensing muscles)
• To avoid activities in which the back is rigid or tense for long periods of time
• To treat attacks of low back pain with light stretching and light activity
• To lift objects using the muscles of the legs and thighs more than the back, and to avoid twisting the back while it is bent

No exercise goals were set, but people were encouraged to set their own exercise goals after speaking with their physicians. The educational messages were repeated at three months and, again, at one year.

Studies suggest that bed rest for longer than 1-2 days does not improve back pain and may, in fact, prolong symptoms. Experts recommend that people with low back pain continue day-to-day activities within the limits permitted by pain. Exercises such as weight lifting that strain the back should be avoided during the first 4-6 weeks of pain. Exercises such as walking and swimming are better choices. Most experts recommend that prolonged sitting (especially with the back unsupported), heavy lifting, and bending/twisting while lifting are strictly avoided.

Tylenol is effective for pain control for people with low back pain. There is no conclusive evidence about whether or not pain control decreases the duration of the back pain episode.

Guidelines/experts suggest that anti-inflammatory medications be used on a regular schedule (roughly every 6-8 hours) for the first few weeks of a back pain bout rather than on an "as-needed" basis to keep the pain (and inflammation) at an acceptable level. These drugs can cause significant side effects, however, such as stomach pain and bleeding ulcers when taken daily and should be used with caution, especially in older individuals who are much more susceptible to developing side effects. They are safer if they are taken with milk or food.

These drugs should generally not be used in those who have kidney problems or are pregnant. People who also have high blood pressure may need to take these medications cautiously.

Cold packs applied to the sore area for the first 2 days may decrease pain and spasm. Inexpensive gel packs are more convenient and less messy than ice. After the first 2 days, switching to heat, particularly moist heat, along with light massage and warm baths may help symptoms. There is no objective evidence that either heat or cold will decrease the overall length of the back pain episode, even though they may provide temporary relief of symptoms.

There is some evidence that muscle relaxants provide short-term symptom relief but no evidence that, when combined with anti-inflammatory medications, the combination is any better than either one by itself. Anti-inflammatory medications remain the preferred choice of treatment, because they cause fewer side effects, are available without a prescription, and are relatively inexpensive.

Narcotics have not been found to be more effective than safer drugs such as Tylenol (acetaminophen) or anti-inflammatory drugs (Motrin, Advil, Aleve, more) in relieving low back pain symptoms. Narcotics can sometimes be used for severe symptoms, but the risk of complications such as drowsiness, depression, and addiction must be carefully considered.

A few studies have shown promising results for early phase low back pain treatment. More study data is necessary for conclusive recommendations.

Shoe insoles may be effective for individuals with low back pain symptoms who stand for prolonged periods. Given the low cost and low potential for ill effects, shoe insoles are sometimes recommended as a treatment option.

Several small studies have suggested that spinal manipulation (chiropractic care) may be helpful for early phase low back pain (first 4 to 6 weeks).

In one small study, individuals who had spinal manipulation used slightly less medication than those who did not. Further study is necessary to draw reliable conclusions.

When a pinched nerve is suspected, however, further tests should be carried out before proceeding with manipulation/chiropractic treatment since spinal manipulation could cause nerve damage in this situation.

Innections are more commonly used for people who have long-standing (chronic) back problems.

Physical therapy/back exercises have not been proven effective for relief of early/acute symptoms, although they may be useful for chronic symptoms and to prevent recurrence.

Reviews of the medical literature have found insufficient evidence to support acupuncture as an effective method for treating early/acute low back pain. The studies that have been done are of poor quality.

There is some evidence to suggest that acupuncture may be helpful for some people who have longstanding (chronic) low back pain.

With TENS treatment, a small electrical stimulation is delivered to the muscles of the low back for the purpose of decreasing pain. According to clinical studies, this procedure appears to be only rarely effective for longstanding back pain. There is no evidence to suggest, however, that it has any effect in treating early/acute back problems.

Corsets and belts have no proven benefit in early phase low back pain treatment. They are occasionally helpful for certain individuals who have longstanding (chronic) back problems.

Studies have failed to show that traction is effective in acute or chronic low back pain treatment.

Biofeedback has no proven benefit in early phase low back pain treatment.

The American Academy of Orthopedic Surgeons, the North American Spine Society, the Institute for Systems Improvement (ICSI) and the Veterans Administration and Department of Defense have published guidelines on low back pain.

These guidelines recommend that a few days of steroid pills may be considered to reduce the nerve irritation when symptoms are severe or fail to improve in people with a "pinched nerve" (disc herniation).

Steroid pills are only effective for short-term pain relief; they do not improve long-term healing, and because of the potential for serious side effects, they are limited to short-term use for people with severe symptoms. They are not recommended for back strain only (when a "pinched nerve" is not present).

A "pinched" nerve (sciatica) is most commonly caused by pressure from a disc (or cushion) that sits between the bones of the spine. The disc can bulge out of place, or a piece can break off and press on a nearby nerve.

In most cases, a pinched nerve (sciatica) gets better without further treatment after a period of rest.

A well-designed five year study of more than 500 back pain sufferers looked at education and reassurance that ordinary, light activity is safe and improves the chance of recovery (Klenerman, Slade; 1995). The study found that people who received this information were much more likely to recover and return to a normal lifestyle than people who did not receive education.

Patients in the study who received education were told that:

• Their low back pain may be caused by a crack in a disc ("cushion") that sits between the bones of the spine that can lead to irritation and swelling;
• The irritation causes spasm (tightening) and stiffness in the nearby muscles that support the back. The tension and high pressure can decrease the flow of blood to these muscles which causes more pain;
• The pain due to muscle spasm causes the back to tense even more, creating a cycle which further increases pain;
• Fear also causes the back muscles to tense even more, which maintains the cycle of increased spasm, pain, and decreased blood flow to muscles;
• The worst thing that a person with back pain can do is to be too cautious and, as a result, tense up his or her back

To improve their condition, people were told:

• That light activity would not worsen their condition and would not further injure the disc ("cushion"). Instead activity could relax the muscles, improve blood flow which helps with healing;
• To walk as normally and as flexibly as possible (without tensing muscles)
• To avoid activities in which the back is rigid or tense for long periods of time
• To treat attacks of low back pain with light stretching and light activity
• To lift objects using the muscles of the legs and thighs more than the back, and to avoid twisting the back while it is bent

No exercise goals were set, but people were encouraged to set their own exercise goals after speaking with their physicians. The educational messages were repeated at three months and, again, at one year.

Tylenol is effective for pain control for individuals with low back pain. There is no conclusive evidence about whether or not pain control decreases the duration of the back pain, but it does help the user to stay comfortable.

Many experts and most guidelines recommend a back exercise program after 4-6 weeks. The goal of exercise is to increase conditioning and to learn proper back posture. Improved fitness will lead to a better ability to participate in physical activities.

It's best to start off with a trained physical therapist who can teach the exercises and monitor activity level so that it increases gradually. Once the program has been learned, people often find that the physical therapist is no longer necessary.

Side effects may include sleepiness, dizziness, and fatigue, but these symptoms often resolve within 2 weeks. Gabapentin (Neurontin) is considered the 'first choice' anticonvulsant and Carbamazepine (Tegretol) the 'second choice' drug.

Guidelines/experts suggest that anti-inflammatory medications (Motrin, ibuprofen, Advil, naproxen, Aleve, more) be used to manage low back pain. These drugs can cause significant side effects, however, such as stomach pain and bleeding ulcers especially when taken daily and should be used with caution, particularly in older individuals who are much more susceptible to developing side effects. Taking them with milk or food, and taking the lowest effective dose tend to help avoid these stomach problems.

These drugs should generally not be used in those who have kidney problems or are pregnant. People with high blood pressure or diabetes may not be able to take anti-inflammatory drugs.

A newer category of anti-inflammatory drugs, called the COX-2 inhibitors (Celebrex, others) can be used in individuals at higher risk for stomach problems, but have side effects of their own, including slightly increased risk of stroke and/or heart attack; they are expensive and only available with a prescription. They are only useful in a small group of people with back pain. Vioxx (rofecoxib), one of the COX-2 inhibitors was taken off of the market recently because of serious heart-related side effects and stroke.

Use of antidepressants for chronic pain may reduce or eliminate the need for antii-nflammatories (Motrin, ibuprofen, Aleve, naproxen, more) or sedatives (sleeping pills). There is evidence that older (tricyclic) antidepressant pills may be more effective than newer SSRIs (Prozac, others) for chronic pain. People who take them should be monitored for side effects which include dry mouth, sleepiness, weight gain, stomach disturbances, and impotence. Major depression associated with low back pain should be treated by a mental health practitioner.

Interventions include individual or family counseling, stress management/relaxation techniques/biofeedback, and psychological crisis intervention.

Because there is little or no evidence of their effectiveness in chronic low back pain, and because of their extensive list of side effects (mental confusion, depression, possible addiction or dependance, more) they generally are not recommended.

A type of antidepressant (tricyclic anti-depressants such as Elavil/amitryptiline or Desyrel/trazodone) are better choices to treat sleep disturbance due to pain, because they also help treat the pain directly and are not addictive.

Steroid pills have not shown any benefit over safer drugs and can cause many serious side effects.

Studies show that chiropractic manipulation is only slightly better than placebo ("fake" treatment) for chronic low back pain (back pain for more than 6 weeks). National guidelines do not recommend chiropractic manipulation for this condition.

With TENS treatment, a small electrical stimulation is delivered to the muscles of the low back, in theory, for the purpose of decreasing pain.

There is insufficient study evidence to recommend TENS alone for the treatment of chronic low back pain (back pain for more than 6 weeks).

Although TENS is often used for chronic back pain, there is little research to support this practice.

There insufficient evidence from medical studies to show definitively whether acupuncture is useful for chronic low back pain.

Additional, well-designed studies are needed for definitive recommendations.

Guidelines/experts recommend against the use of narcotics for chronic pain. Concerns about side effects such as drowsiness or depression and addiction to narcotics are issues when using these drugs long-term. If these drugs are used they should be limited to a brief period of time.

In this procedure, a steroid medication is injected into the back near the nerve that is being pinched or irritated. Studies have shown that steroid injections improve shooting nerve pain (from a pinched nerve). The injection is relatively safe with few minor potential complications if performed by a specialist trained in the technique.

With this procedure, steroids are injected into a muscle in the back. Some experts believe that they may provide some relief for people who seem to have muscle tightness in a particular location ("trigger point") in the back, but have not been found to be useful for those who do not have specific "trigger points". There have been no high quality clinical studies of "trigger point" injections.