A review of 80-plus studies upends the conventional wisdom.

Julia Belluz

Cathryn Jakobson Ramin’s back pain started when she was 16, on the day she flew off her horse and landed on her right hip.

For the next four decades, Ramin says her back pain was like a small rodent nibbling at the base of her spine. The aching left her bedridden on some days and made it difficult to work, run a household, and raise her two boys.

By 2007, she couldn’t so much as sit or walk for more than a few minutes without experiencing what felt like jolts of electricity shooting up and down her spine.

In 2008, after Ramin had exhausted what seemed like all the options, her doctor recommended nerve decompression surgery. But the $8,000 operation didn’t fix her back, either. The same pain remained, along with new neck aches.

At that point, Ramin decided to deploy her skills as a journalist and investigate the $100 billion back pain industry. She went on to write Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery, an incredible tale of back pain and its treatment, published last May.  The big takeaway: Millions of back patients like Ramin are floundering in a medical system that isn’t equipped to help them. They’re pushed toward intrusive, addictive, expensive interventions that often fail or can even harm them, and away from things like yoga or psychotherapy, which actually seem to help. Meanwhile, Americans and their doctors have come to expect cures for everything — and back pain is one of those nearly universal ailments with no cure. Patients and taxpayers wind up paying the price for this failure, both in dollars and in health.

Thankfully, Ramin finally discovered an exercise program that has eased her discomfort. And to this day, no matter how busy her life gets, she does a series of exercises every morning called “the McGill 3” (more on them later). “With very rare exceptions,” she says, “I find time to exercise, even when I’m on the road.”

More and more people like Ramin are seeking out alternative therapies for back pain. While yoga, massage, and acupuncture have been around for a long time, there was little high-quality research out there to understand their effects, and doctors often looked down on the practices. But over the past decade, that’s changed.

To learn more, I searched the medical literature on treatments for lower back pain (the most common type) and read through more than 80 studies (mainly reviews of the research that summarized the findings of hundreds more studies) about both “active” approaches (yoga, Pilates, tai chi, etc.) and passive therapies (massage, chiropractics, acupuncture, and so on). I also talked to nine experts and researchers in this field. (For more detail on our methods, scroll to the end.)

What I found surprised me: Many of these alternative approaches really do seem to help, though often with modest effects. But when you compare even those small benefits with the harm we’re currently doing while medically “treating” back pain, the horror of the status quo becomes clear. “No one dies of low back pain,” one back pain expert, University of Amsterdam assistant professor Sidney Rubinstein, summed up, “but people are now dying from the treatment.”

Mainstream medicine has failed people with chronic back pain

Lower back pain is one of the top reasons people go to the doctor in the US, and it affects 29 percent of adult Americans, according to surveys. It’s also the leading reason for missing work anywhere in the world. The US spends approximately $90 billion a year on back pain — more than the annual expenditures on high blood pressure, pregnancy and postpartum care, and depression — and that doesn’t include the estimated $10 to $20 billion in lost productivity related to back pain.

Doctors talk about back pain in a few different ways, but the kind most people (about 85 percent) suffer from is what they call "nonspecific low back pain." This means the persistent pain has no detectable cause — like a tumor, pinched nerve, infection, orcauda equina syndrome.

About 90 percent of the time, low back pain is short-lived (or in medical lingo, “acute”) and goes away within a few days or weeks without much fuss. A minority of patients, though, go on to have subacute back pain (lasting between four and 12 weeks) or chronic back pain (lasting 12 or more weeks).

Chronic nonspecific back pain is the kind the medical community is often terrible at treating. Many of the most popular treatments on offer from doctors for chronic nonspecific low back pain — bed rest, spinal surgery, opioid painkillers, steroid injections — have been proven ineffective in the majority of cases, and sometimes downright harmful.

Consider opioids. In 2017, more than 30,000 Americans will die from opioid overdoses. Opioid prescribing is common among people with back pain, with almost 20 percent receiving long-term opioid prescriptions.

Here’s the outrageous part: All these opioids were being prescribed before we actually knew if they helped people with chronic lower back pain. It gets worse: Now high-quality evidence is coming in, and opioids don’t actually help many patients with chronic low back pain.

This soon-to-be-published randomized controlled trial was the first to compare the long-term use of opioids versus non-opioid medications (such as anti-inflammatory drugs and acetaminophen) for low back pain.

After a year, the researchers found opioids did not improve patients’ pain or function, and the people on opioids were actually in slightly more pain compared to the non-opioid group (perhaps the result of “opioid-induced hyperalgesia” — heightened pain brought on by these drugs).

As for surgery, only a small minority of patients with chronic low back pain require it, according to Up-To-Date, a service that synthesizes the best available research for clinicians. In randomized trials, there was no clinically meaningful difference when comparing the outcomes of patients who got spinal fusion (which has become more and more popular in the US over the years) with those who got a nonsurgical treatment.

Steroid injections for back pain, another popular medical treatment, tend to have similarly lackluster results: They improve pain slightly in the short term, but the effects dissipate within a few months. They also don’t improve patients’ long-term health outcomes.

It’s not entirely surprising that the surgeries, injections, and prescription drugs often fail considering what researchers are now learning about back pain.

Historically, the medical community thought back pain (and pain in general) was correlated to the nature and severity of an injury or anatomical issue. But now it’s clear that what’s going on in your brain matters too.

“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," Roger Chou, a back pain expert and professor at Oregon Health and Science University, summarized.

For example, when you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.

The awareness about the role psychological factors play in how people experience pain has grown more widespread with the general shift away from the dualist view of the mind and body toward the more integrated biopsychosocial model. Chronic nonspecific low back pain “should not been considered as a homogenous condition meaning all cases are identical,” researchers in one review of the research on exercise cautioned.

A new understanding of pain called “central sensitization” is also gaining traction. The basic idea is that in some people who have ongoing pain, there are changes that occur between the body and brain that heighten pain sensitivity — to the point where even things that normally don’t hurt are perceived as painful. That means some people with chronic low back pain may actually be suffering from malfunctioning pain signals.

Enter alternative therapies for chronic back pain

Despite the clear risks, doctors have continued to prescribe painkillers, and perform surgeries and injections, sometimes to patients who won’t take no for answer or who can’t afford to try alternatives (which usually aren’t covered by insurance plans).

Slowly, though, the tide is shifting.

Medical societies and public health agencies are now advising doctors to try less invasive options and even alternative therapies such as acupuncture before considering opioids or surgery.

Most recently, in February 2017, the American College of Physicians advised doctors and patients try “non-drug therapies” such as exercise, acupuncture, tai chi, yoga, and even chiropractics, and avoid prescription drugs or surgical options wherever possible. (If the non-drug therapies fail, they recommended nonsteroidal anti-inflammatory drugs as a first-line therapy, or tramadol or duloxetine as a second-line therapy before opioids.)In March 2016, the Centers for Disease Control and Prevention also came out with new guidelines urging health care providers to turn to non-drug options and non-opioid painkillers before considering opioids.

At the same time, research has mounted suggesting alternative therapies (acupuncture, massage, spinal manipulation) can be effective — with the caveat that they’re often no panacea and the effects tend to be short-lived and moderate.

But most of the alternatives also carry little or no harm (except to patients’ pocketbooks) — which makes them all the more appealing amid the historic drug crisis.

“We have a slew of modalities and procedures that the American College of Physicians cannot endorse — such as opioids, fusion surgery, such as injections,” Ramin said, because there’s now so much evidence of ineffectiveness or harm. “So all those things are off the table, and now they are looking for things they can endorse that will not cause harm.”

Moving is probably the most important thing you can do for back pain

When back pain strikes, your first instinct may be to avoid physical activity and retreat to the couch until the pain subsides.

But doctors now think that in most cases, this is probably the worst thing you can do. Studies comparing exercise to no exercise for chronic low back pain are consistently clear: Physical activity can help relieve pain, while being inactive can delay a person’s recovery.

Exercise is helpful for a number of reasons: It can increase muscle strength, which can help support the spine; It can improve flexibility and range of motion in the back, which can help people’s functional movement and get them back to their normal living; it can boost blood flow to the soft tissues in the back, which promotes healing and reduces stiffness.

Researchers in this 2016 review of the research on exercise for chronic nonspecific low back pain summarized exercise’s range of benefits, including these pretty amazing findings:

“Aerobic exercise for 20 min on a cycle ergometer at 70% peak oxygen uptake reduced the pain perception for more than 30 min for patients with [chronic low back pain].”

“Improving the flexibility of the lumbar spine and hamstrings can significantly reduce [chronic low back pain] by 18.5%–58%.”

“Core stabilization programs have been shown to significantly reduce [chronic low back pain] by 39%–76.8%, and a muscular strength program significantly reduced [back pain] by 61.6%.”

Those researchers suggested that a combination of exercises — strength training, aerobic exercise, flexibility training — may be most helpful to patients, and that there seemed to be no clear winners among the different approaches but that each had its own benefits.

“My general take,” Chou said, “is that all [exercise types] seem to work.” If people find a program they like and stick to it, he added, they’ll probably see benefits not only with their back but with their overall health and sleep patterns, too.

To be clear, this doesn’t mean you should play full-contact sports like football or hockey with a bad back, and exercise doesn’t always help with those short-lived acute episodes. But if you have chronic back pain, you’ll want to find ways to work through the pain and keep active. Next, we’ll turn to some more specific exercises that are popular (and well studied) for back pain.