According to the National Institute of Neurological Disorders and Stroke, lower back pain is the most common cause of work-related disability and a leading contributor to job-related absenteeism in the United States. Approximately 85% of adults suffer from this at some time during their lives. Lower back pain is one of the top reasons people pay their doctors a visit, yet there's relatively little agreement on what works best to relieve the problem.

Overtreatment
Americans are spending $90 billion a year in care for aching backs — from MRIs to pain pills to nerve blocks to acupuncture. There is little evidence that patients got much better as the bill soared over the past decade. Time often is the best antidote. Most people will experience back pain at some point, but up to 90 percent will heal on their own within weeks. In fact, for run-of-the-mill cases, doctors aren't even supposed to do an X-ray or MRI unless the pain lingers for a month to six weeks. Yet a study in 2009 found nearly one in three aching Medicare patients get some kind of back scan within the first month.

X-rays, CT scans and MRIs may be routinely ordered for people with low back pain, but often these tests are unnecessary, according to new 2011 guidance from the American College of Physicians. These imaging tests have the potential to cause harm by exposing people to unnecessary radiation and by uncovering abnormalities -- such as a bulging disc -- that may not be causing the symptoms. However, once such abnormalities are uncovered, they may be treated, potentially with an unneeded surgery.

Subacute low back pain treatment
No treatments, physical therapy or otherwise, have been proven effective for lower back pain that is "subacute." This is pain that is neither new nor chronic -- that is, present for more than 6 weeks, but less than 3 months. Exercise therapy, or even some advice from a physical therapist, may help some people with lower back pain.  

Low back pain treatment
There are some people who benefit from one or more of these low back pain treatment options:

Pain-relieving and anti-inflammatory medications.
A cold compress immediately after the injury to reduce swelling.
Heat on the back several days after the injury to help relax muscles.
A very short period of bed rest to allow muscles to heal.
Gentle exercises to stretch and strengthen back muscles. Yin yoga, or relaxation yoga, is a good option.

Stretch a few times a day
Some people like to use an inverted board to lay upside down for self-traction
Fish oil supplements could reduce inflammation
Exercise to strengthen the core muscles
Specific exercises to strengthen the muscles around the lumbar region.

For people who suffer from acute low back pain, adding chiropractic spinal adjustments to standard care -- such as managing pain and taking painkillers -- does not appear to generate a greater early reduction in pain compared with standard care alone. Annals of the Rheumatic Diseases, August 2009.

Supports are not effective
Lower-back supports are not helpful in preventing or managing back pain. Many people with chronic low back pain wear wide belts called lumbar supports when performing heavy lifting or other tasks that stress the back. Some workers also wear the supports in the hopes of preventing on-the-job injuries. Dutch researchers found that across 15 clinical trials involving more than 15,000 people, there was no clear evidence that lumbar supports were effective. Cochrane Library, online April 16, 2008.

TENS unit
People with chronic low back pain who seek relief with transcutaneous electric nerve stimulation or TENS do not get much benefit in pain relief. However, the technique can be effective in relieving diabetic nerve pain, also called diabetic neuropathy. Neurology, January 12, 2010.

Exercise and physical activity
Exercise may help ease the discomfort -- just as long as the exercise is not specifically targeting the back. Researchers found that of the nearly 700 patients with low back pain they followed for 18 months, those who walked and got other forms of "recreational" exercise had a lower risk of pain over time. In contrast, those who performed exercises specifically for their backs appeared to make matters worse. Lower back pain is one of the most common reasons for Americans' trips to the doctor, and the top reason people seek alternative therapies like acupuncture. Chiropractors and physical therapists often prescribe exercises to mobilize and strengthen the lower back, but growing evidence suggests that targeting the back does not help, and may even aggravate, the pain. The findings, published in the American Journal of Public Health in October 2005, add to that notion-and point to the benefits of general activity like brisk walking or swimming.

Yoga and low back pain
People plagued by chronic lower backaches may find some relief in yoga class. Their study of 101 adults with persistent low back pain found that a gentle yoga class seemed to be a better alternative to either general exercise or a self-help book. Though people in the exercise class eventually improved to a similar degree as their yoga-practicing counterparts, yoga class brought quicker results. The study participants took a slower-moving form of yoga that was designed for people with lower back problems. Vigorous styles of yoga that include more-advanced poses could potentially make chronic back pain worse. It's estimated that 14 million Americans practice yoga, often as a way to treat chronic aches and pains. But, in the Western medical literature at least, there have been no published studies on the effects of yoga on chronic back pain. Researchers randomly assigned 101 adults to take either 12 weeks of yoga class or 12 weeks of a standard therapeutic exercise class, or to follow the advice of a self-care book. The yoga class was conducted in what's known as the viniyoga style, which goes by the philosophy that poses should be adapted to the individual's needs. The instructor was experienced in therapeutic yoga, and the class was limited to basic poses that would not put too much strain on the back, Sherman explained. After 12 weeks, the yoga practitioners reported better back function than their peers in either of the other two groups. After another three months, those in the exercise group had improved to a similar degree as the yogis. One difference between the yoga practitioners and other two groups that remained over the long haul: At the last evaluation, the yogis were using less than half the amount of pain medication their peers were. Viniyoga, like other forms of yoga, focuses on coordinating movement with the breath and focusing the mind. It's possible that yoga allowed the back pain sufferers to become more aware of their habitual movements and postures that may have been contributing to their back problems in the first place. SOURCE: Annals of Internal Medicine, December 20, 2005.
   My comments: I particularly like yin yoga classes.

Alexander technique
Chronic back pain can be eased by teaching the Alexander technique, an alternative therapy involving learning better posture. Researchers from the University of Southampton and the University of Bristol compared the effectiveness of different therapies in more than 500 patients. After a year of treatment, patients receiving 24 Alexander technique lessons reported experiencing just three days of back pain, compared to 21 days for those given normal care by their doctor. Alexander technique was originally developed at the end of the 19th century by the Shakespearean actor Frederick Alexander.

Acupressure
Results of a study from Taiwan indicate acupressure is better at decreasing the pain and disability of lower back pain than conventional physical therapy. Researchers recruited 129 patients who had chronic lower back pain for more than 4 months. Sixty-four patients were randomly assigned to acupressure and 65 to physical therapy, which included such measures as pelvic manual traction, spinal manipulation, thermotherapy, infrared light therapy, electrical stimulation and exercise therapy. Each subject received six sessions of treatment within 1 month. Disability questionnaire scores showed significantly more improvement in the acupressure group at the end of treatment. The improvements were maintained at the 6-month follow-up. The patients receiving acupressure also reported greater improvement in leg pain, pain that interfered with normal work, and days off from work or school. Source: BMJ Online First 2006.

Acupuncture and Low Back Pain
Acupuncture improves low back pain, compared with no treatment. However, minimal intervention consisting of superficial needle placement at non-acupuncture points resulted in similar improvements. Past studies have yielded inconclusive results concerning the effectiveness of acupuncture to treat lower back pain. German researchers tested 300 patients to assess the effectiveness of acupuncture for lower back pain. The patients were randomly assigned to "real" acupuncture treatment, "sham," or "minimal" acupuncture, or no acupuncture treatment. Real and minimal acupuncture consisted of 12 treatment sessions over 8 weeks. All subjects completed a pain questionnaire at 8, 26 and 52 weeks. After 8 weeks of treatment, pain intensity had decreased by 28 percent in the acupuncture group, 23 percent in the minimal acupuncture group, and 7 percent in the control group. At weeks 26 and 52, back pain was still reduced, with no significant differences between the full-acupuncture and the minimal-acupuncture group. Source: Archives of Internal Medicine, 2006.

Surgery
Many people with lower back pain caused by spinal disc degeneration need not resort to surgery for relief. Non-invasive treatments -- including physical therapy and anti-inflammatory painkillers -- should be the first, and often only, measure for most people with the problem. Journal of the American Academy of Orthopedic Surgeons, February 2009.

Low back pain at work
People who lift boxes and packages all day need to take longer and more frequent breaks to avoid suffering injury. This is especially true for people new to the job. The risk of low back pain and injury is greatest towards the end of a work shift when fatigue sets in.

Pregnancy
Gentle manipulation from an osteopathic doctor may relieve late-pregnancy back pain that frequently hinders bending, lifting, or walking. American Journal of Obstetrics and Gynecology, 2010.
   Water aerobics can help ease the pelvic and back pain that plague many women during pregnancy. Among healthy pregnant women, those who do water aerobics report less low back pain and less work missed than those who perform land-based exercise. More than one third of women experience low back pain during pregnancy, which can increase the risk of suffering this type of pain later on.

Pain medicine for low back pain
Opioid pain killers may provide no advantage over non-opioids for relieving chronic low back pain, but carry a high risk of addiction. Low back pain is one of the most common symptom encountered by doctors in the US. When treatments such as exercise therapy and non-steroidal anti-inflammatory drugs (NSAIDs) fail to control the pain, doctors may turn to prescription opioid painkillers. Dr. David A. Fiellin, from Yale University in New Haven, Connecticut analyzed data from 38 studies that looked at the use of opioids for low back pain. Opioid prescribing rates for back pain varied widely between studies, ranging from 3 percent to 66 percent. Data gathered from four studies revealed no significant pain-relieving advantage for opioids over either placebo or nonopioid controls. Similarly, an analysis of data from five studies comparing the benefit of different opioids showed only a nonsignificant drop in pain from baseline. The percentage of subjects with a substance use disorder at some point in their lives ranged from 36 percent to 56 percent. Up to 43 percent of subjects had a current substance use disorder. Between 5 percent and 24 percent of subjects showed "aberrant medication-taking behaviors." "The findings in this review suggest that clinicians should reconsider treating chronic low back pain with opioid medications, and consider other treatments with similar benefit yet fewer long-term adverse effects," says Dr. David A. Fiellin. Annals of Internal Medicine, 2007.

Low back pain surgery
Two big government-funded studies for low back pain surgery for painful herniated disks show no clear-cut reason to choose an operation over other treatment. The pain and physical function of the patients, who were suffering from a condition called sciatica, improved significantly after two years whether or not they had low back pain surgery. However, neither strategy offered complete relief. The condition involves disk cartilage bulging between vertebrae in the lower spine and pressing against a nerve. It can cause excruciating burning pain called sciatica, radiating from the lower back into the legs; patients often have difficulty walking. About 250,000 Americans have disk surgery for sciatica each year, while another quarter-million instead choose physical therapy, painkillers or rest until they feel better.

Sciatica is caused by pressure or injury to the sciatic nerve, located in the back of the leg. Symptoms include pain, numbness or weakness in the leg. A herniated disc is a frequent cause of this condition. While open surgery has been traditional used to correct this condition, an approach that requires a smaller incision -- "percutaneous discectomy"-- is now possible. Instruments sold in the 1980s did not work very well for percutaneous discectomy, so many physicians remain skeptical. But with new devices, available since 2000, the success rate has been significantly higher. The procedure is performed by inserting a thin tube into the herniation, through which a portion of the disc's nucleus can be vaporized or suctioned out. However, percutaneous discectomy is not for all patients with back pain. If the pain is not caused by pressure on the nerve or inflammation, those patients will probably do better with surgery. Also, if the disc herniation is pinched off from the adjacent disc or has become fragmented and migrated into the spinal canal, the patient will require traditional surgery.

Cause of Low Back Pain
Obvious causes include lifting a heavy object, making a sudden twisting motion with your torso, sitting in one position for a long time, for example in front of the computer, or from an injury or accident. Sitting in an upright 90-degree position places more strain on the back than sitting in a slightly reclined 135-degree position. The back region is complex and hence there are several possible sources or causes, the most often being spasms of the large, supportive muscles alongside the spine. Other common causes of low back pain are:

* Ruptured or herniated disk - this can cause intense low back pain radiating to the buttocks, thigh or leg. The likelihood of developing low back pain from disc disease may be partially inherited.
* Poor alignment of the vertebrae - this is a common low back pain cause the chiropractors refer to when they try to readjust the back.
* Spinal stenosis (narrowing of the spinal canal)
* Strain or tears to the muscles or ligaments supporting the back - this is a very difficult low back pain cause to diagnose since it does not show up on a X-ray projection
* Small fractures to the spine from osteoporosis
* Degeneration of the disks
* Spine curvatures (like scoliosis or kyphosis) which may be inherited and seen in children or teens
* If the discomfort continues for several months, getting worse, and therapy is not helping, one should rule out more serious causes such as cancer metastases or ankylosing spondylitis.

Additional causes are from organs in the pelvis or elsewhere. These include bladder infection, kidney stone, endometriosis, ovarian cancer, and ovarian cysts.

Those who work in construction or another job requiring heavy lifting, that includes lots of bending and twisting, or whole body vibration (like truck driving or using a sandblaster) are more likely to have a job related injury. As people get older, they are more likely to have low back pain, particularly if they have poor posture, are overweight, smoke, have arthritis or osteoporosis, and feel stress or have low mood or depression. Pregnancy can be a cause for low back pain.

Sports activity as cause
Years of competitive sports may raise teenagers' risk of developing lower back pain. A study, of nearly 4,700 18-year-old college students, found that those who had been involved in sports since elementary school had higher rates of low back pain than their less-competitive peers. American Journal of Sports Medicine, online January 5, 2010.

Athletes
Young people who play baseball or swim competitively may start to show wear and tear in the spinal discs as early as college. In a study of 308 college athletes, Japanese researchers found that baseball players and swimmers were three times more likely than a group of non-athlete students to show degeneration in the discs of the lower spine and more likely to have low back pain. Athletes in several other sports -- including basketball, soccer and running -- showed no such elevated risks. Baseball and swimming may be particularly hard on the discs of the lower spine because the sports involve repeated rotations of the torso. American Journal of Sports Medicine, 2009.

Diagnosing the problem
A simple diagnostic imaging procedure can help identify patients with lower back pain who would benefit from spinal injections and spare those who would not.  Single photon emission computed tomography (SPECT) shows abnormal activity of cells in the spine, which can help doctors identify problems that may be causing a patient's symptoms. Chronic lower back pain is often caused by degenerative changes in the spine and is commonly treated by steroid and anesthetic injections to the small joints of the spine called the facet joints. Facet joint injections can be a good short-term treatment alternative in some patients, but these injections don't help all patients, are relatively expensive and can cause complications,. Bone SPECT can help identify the patients with lower back pain who would benefit from facet joint injections. The patients with negative bone SPECT should be spared the injections.

Routine use of costly X-ray, MRI and CT scans on patients with lower back pain may be unnecessary. While most patients have no serious underlying condition causing the low back pain, doctors often order imaging procedures that can check for problems like herniated disks, muscle injuries, arthritis or broken bones.
Dr. Roger Chou of Oregon Health and Science University in Portland assessed the results of six studies involving 1,800 people with lower back pain. Patients who had no sign of a serious underlying cause but were given an imaging test fared no better than other patients who received standard treatment but no imaging. The imaging tests can be expensive, and expose patients to low doses of radiation that potentially raise cancer concerns.

Questions
Do serrapeptase or another product called nattokinase help with low back pain?
   We have not seen good research in this area.

What are your thoughts about kava for chronic low back pain?
   Since kava is not recommended to be used for regular, prolonged periods, it would not be a good option for chronic low back pain. However, kava can be used occasionally not necessarily for pain, but as a gentle muscle relaxer. If the back pain is due to muscle spasm, kava can be slightly helpful and be a way to use less prescription medicines. This way it can partially substitute for pain meds on the days that kava is used.

My husband has had 3 failed back surgery's and they have told him he has nerve damage in his lower back and there is nothing they can do. He has tried all kinds of drugs for low back pain and nothing worked. He now has to take pain pills 24/7. Help! What natural supplement might give him some relief?
    We are not aware of a potent natural pain medication that provides full low back pain relief but some of the suggestions at the top of the page could be tried.

What is your recommendation out of the herbs you offer to treat sciatica and chronic pain? I receive your newsletter and appreciate what you write.
    I am not aware of natural herbs that treat sciatica effectively.