Lower back pain: what helps, from medication to physio

Lower back pain is almost universal.

Around 80 percent of British adults experience a significant episode at some point, and it is the leading cause of years lived with disability in the United Kingdom.

The vast majority of cases are mechanical and self-limiting, settling within six weeks with sensible movement, analgesia and reassurance. A small but important minority signal something more serious.

This guide distinguishes the two, explains which medicines and physical treatments actually help, and sets out when to escalate care.

What do we mean by lower back pain?

Non-specific low back pain refers to pain between the lower rib margin and the gluteal folds, with or without referred leg pain, that does not have a specific diagnosable cause such as a fracture, infection or malignancy. Sciatica describes pain radiating below the knee in a dermatomal pattern, usually from nerve-root irritation at L4, L5 or S1. The NHS back pain page and the charity Versus Arthritis both offer excellent patient materials.

Red flags: when to seek urgent help

Call 999 or go to A and E for new loss of bladder or bowel control, saddle numbness, or rapidly progressive leg weakness, which may indicate cauda equina syndrome.

Book urgent same-day or same-week review for fever with back pain, unexplained weight loss, history of cancer, recent significant trauma, progressive neurological deficit, or severe night pain not relieved by position.

Thoracic pain and pain that radiates into the abdomen also need prompt assessment.

The first six weeks: what actually helps

For uncomplicated acute low back pain, the single most important message is to keep moving within the limits of comfort. Prolonged bed rest delays recovery.

Gentle walking, returning to normal activity as tolerated, and avoiding fear-avoidance behaviour predict a shorter episode than strict rest.

Simple analgesia

Paracetamol alone is modestly effective and often not enough. Non-steroidal anti-inflammatory drugs are the mainstay of acute pharmacological treatment when no contraindication exists.

• Naproxen 250 to 500 mg twice daily is my usual first choice for adults without gastric or renal contraindications. It has a reasonable cardiovascular safety profile compared with other NSAIDs.
• Diclofenac is effective but has a higher cardiovascular risk signal; it is now reserved for short courses where alternatives have failed.
• Meloxicam 7.5 to 15 mg once daily offers once-daily dosing with a relatively favourable gastrointestinal profile.
• Etoricoxib, a COX-2 selective agent, lowers the risk of upper gastrointestinal bleeding but should not be used in uncontrolled hypertension or established cardiovascular disease.

All oral NSAIDs should be taken at the lowest effective dose for the shortest time needed, usually with a proton pump inhibitor in anyone aged over 65, on antiplatelet or anticoagulant therapy, or with previous peptic ulcer disease. The BNF NSAID prescribing summary gives the full cautions list. Our NSAIDs treatment hub compares the agents side by side.

Topical NSAIDs

Topical diclofenac or ibuprofen gel, rubbed into the painful area three or four times daily, delivers useful relief with much lower systemic exposure than oral tablets. They are particularly helpful for localised back and paraspinal muscle pain in older adults where oral NSAIDs would be risky.

What about opioids?

NICE guidance actively discourages opioids, including codeine and tramadol, for acute or chronic non-specific low back pain, because evidence for sustained benefit is weak and risks of dependence and adverse effects are high.

A very short course, three to five days, may be considered for severe acute pain when NSAIDs are contraindicated, under GP supervision.

Chronic opioid use for back pain is associated with worse long-term outcomes.

Muscle relaxants and others

Diazepam may occasionally be useful for severe painful muscle spasm for a maximum of five to seven days.

Amitriptyline and duloxetine are considered when pain persists beyond 12 weeks and has a neuropathic component; they are not first line for acute mechanical pain.

Gabapentin and pregabalin are not recommended for non-specific low back pain.

Physiotherapy: when, and what kind?

NICE recommends offering a group exercise programme or supervised physiotherapy when symptoms persist beyond a few weeks or are severe from the start.

The specific modality matters less than the consistency of movement: graded aerobic activity, core conditioning, and progressive strengthening all help.

Manual therapy such as spinal manipulation or mobilisation can be added, but only as part of a package that includes exercise.

Self-referral to NHS musculoskeletal physiotherapy is now available in most parts of England and Scotland without a GP letter. The wait can be a few weeks; in the interim, free guided-exercise videos from Versus Arthritis and the NHS are a reasonable starting point. Our musculoskeletal treatment hub and the broader pain relief guide place physiotherapy in context.

Chronic and recurrent low back pain

Pain persisting beyond 12 weeks deserves a slightly different approach. The biomedical model alone is not enough.

Good chronic pain management combines continued exercise, cognitive behavioural therapy-informed self-management, sleep hygiene, mood support, and judicious medication use.

Duloxetine or low-dose amitriptyline are considered when a neuropathic component is likely.

Facet joint or epidural steroid injections have a limited role, usually for targeted indications decided in specialist clinics.

Surgery for non-specific low back pain is rarely helpful and is not routinely recommended.

Discectomy is considered for persistent, severe sciatica with clear nerve-root compression on MRI that has failed at least six weeks of conservative treatment.

Spinal fusion for mechanical low back pain without a specific structural cause has poor long-term outcomes and is not supported by current NICE guidance.

Everyday prevention: what you can do now

• Stay active. Regular walking, swimming or cycling protects the back better than any gadget or belt.
• Strengthen the core. Pilates, yoga and resistance training all reduce recurrence.
• Lift carefully. Keep loads close to the body, hinge at the hips, avoid twisting under load, and share heavy loads.
• Set up your workstation. Screen at eye level, feet flat, elbows at right angles, and stand or walk every 30 to 45 minutes.
• Stop smoking. Smoking impairs disc nutrition and predicts poorer back-pain outcomes.
• Manage weight. Losing 5 to 10 percent of body weight, where relevant, reduces mechanical load on the lumbar spine.
• Sleep well. Poor sleep amplifies pain; a medium-firm mattress suits most adults.

Imaging: usually not needed

X-rays, CT and MRI are not routinely indicated for non-specific low back pain in the first six weeks.

They frequently show age-related changes that do not correlate with symptoms and can prompt unnecessary anxiety and intervention.

Imaging is reserved for red flags, persistent radicular pain considered for surgery, or failure to improve after adequate conservative treatment.

Frequently asked questions

Should I rest or stay active when my back hurts?

Stay active within comfort. Avoid bed rest beyond a day or two. Evidence consistently shows that graded activity leads to faster recovery and less recurrence than prolonged rest.

Is heat or ice better?

Either can help; use whichever feels better. Heat often eases muscle tightness, while ice may settle an acute flare. Neither changes the underlying course, so use them for comfort alongside movement and analgesia.

Do I need a back brace?

Routine lumbar supports or corsets are not recommended for non-specific low back pain. They provide short-term comfort but may weaken supporting muscles with prolonged use.

Can an online doctor prescribe NSAIDs for my back?

Yes, within limits. A proper online assessment should screen for gastric, renal and cardiovascular contraindications, assess red flags and offer a short course with clear review arrangements. Any site dispensing NSAIDs without an assessment is acting outside UK regulation.

What about private MRI scans advertised directly to patients?

Be cautious. Without a clinical question, a scan often generates incidental findings that lead to anxiety, further tests and occasionally surgery that was not needed.

If you have persistent or red-flag symptoms, ask your GP or physiotherapist whether imaging is indicated first.

Sciatica: a special case

Sciatica, pain radiating below the knee in a dermatomal pattern, is the back-pain subgroup most often mishandled. The good news is that around three quarters of cases settle within six to twelve weeks with conservative treatment, even when MRI shows a disc protrusion. Regular neuropathic pain agents such as gabapentin and pregabalin are no longer recommended first line for sciatica; evidence showed limited benefit and meaningful side effects including weight gain and drowsiness. A short course of an NSAID such as naproxen with PPI cover, gentle mobility work, and graded physiotherapy remains the mainstay. Amitriptyline or duloxetine may be considered when neuropathic pain is prominent. Persistent severe sciatica with corresponding MRI findings, after at least six weeks of conservative treatment, is the population in whom spinal surgery has clearest evidence of benefit, though even then the gains fade over one to two years.

Lower back pain at work and in athletes

Occupation is a strong determinant of outcome. Jobs that combine heavy lifting, awkward postures, vibration and shift work have higher chronicity rates.

The aim after an acute episode is graded return rather than complete avoidance; remaining off work for more than a few weeks predicts worse long-term outcomes independent of initial severity.

Occupational health teams, phased return plans, ergonomic adjustments and temporary modified duties all help.

A sick note for a fortnight is occasionally necessary, but the goal is never the note itself, it is the plan around it.

In recreational and competitive athletes, most low back pain is mechanical and overuse-related.

Rotational sports such as golf, cricket and tennis commonly provoke facet-joint and paraspinal muscle pain, while runners tend toward sacroiliac and gluteal medius-related pain.

A specific sports-physiotherapy assessment, with targeted strengthening of the hip abductors, deep core stabilisers and posterior chain, usually resolves the problem within eight to twelve weeks without loss of training.

When back pain becomes chronic: self-management that works

Chronic primary back pain, where pain has persisted beyond three months without a specific structural cause, responds best to multimodal self-management rather than escalating drugs.

The programme I recommend to my own patients has four threads.

The first is continuing aerobic exercise most days, even when pain is present, calibrated to not flare symptoms for more than 24 hours.

The second is a realistic pacing plan: breaking activities into shorter bouts and avoiding boom-and-bust cycles.

The third is sleep and mood, including cognitive behavioural therapy when low mood or catastrophising become predominant; NHS Talking Therapies accept self-referrals in England.

The fourth is medication de-escalation: stepping off any long-term opioid, gabapentinoid or benzodiazepine that is not clearly helping, with GP supervision.

Social support matters. Patients who continue working, stay connected socially and remain physically active recover faster than those who withdraw.

Flare-ups are not setbacks but expected events; a simple written flare plan agreed with your physiotherapist turns a frightening experience into a manageable one.

Conclusion

For most British adults with lower back pain, the plan is simple: keep moving, use a short course of a well-chosen NSAID with gastric protection where appropriate, try topical options if oral ones are risky, and add supervised exercise or physiotherapy if symptoms persist beyond a few weeks.

Seek urgent help for red flags, avoid opioids for anything more than a very short episode, and remember that the spine is far more resilient than it often feels.

With active rehabilitation, the large majority of episodes settle.

This article is for information only. If your pain is severe, progressive, or accompanied by any red-flag symptoms, contact NHS 111 or your GP straight away.