Back pain is close to universal. Something in the order of eight in ten adults in the UK will have an episode at some point, musculoskeletal problems account for roughly a third of GP consultations in England, and low back pain is among the leading causes of years lived with disability in this country. It is not a niche complaint, and it is not usually a serious one.
That last point is worth holding on to, because the way back pain feels and the way it behaves are two different things. A first episode can be genuinely frightening, and the great majority of frightening episodes settle without anything dramatic happening.
How ordinary back pain behaves
Most low back pain is described in the NHS and in clinical guidance as non specific, which is an unsatisfying label with an important meaning: no single structure can be identified as the culprit, and no single structure needs to be. Muscles, joints, discs and ligaments share the load and share the blame, and the pain usually reflects the whole region being irritated rather than one part being damaged.
The typical course is a sharp start, a rough few days, a noticeable improvement over two to six weeks, and a slow tail of stiffness. Recurrence is common and is not evidence of failure. Sciatica, where pain runs down a leg from a nerve root irritated in the lower back, tends to be slower, often four to six weeks and sometimes longer, but it also usually settles without surgery.
Severe pain is not the same as serious damage. The back can produce a great deal of one with very little of the other.
The first week, and what actually helps
UK guidance has changed considerably in the past decade, and the biggest change is the disappearance of rest. Lying flat for a few days used to be standard advice. It is now specifically discouraged, because it prolongs the episode rather than shortening it.
- Keep moving, at whatever level is possible. Carry on with normal activities as far as pain allows, even if that means shorter walks and slower stairs. Movement is treatment, not a reward for having recovered.
- Stay at work if you reasonably can, with adjustments if needed. Long absence makes returning harder, and light duties beat a fortnight on the sofa.
- Use heat for comfort. A hot water bottle or a heat pack against the sore area eases muscle guarding for many people. It changes nothing structurally, and it does not need to.
- Break up sitting. Change position every twenty or thirty minutes. Sitting still is what most people find hardest in the first week.
- Sleep in whatever position is least painful, with a pillow between or under the knees if it helps. The sleeping position guide goes into the detail.
- Start gentle movement early. Knee rolls, pelvic tilts and short walks, well before it feels fully better. A starting set is here.
What does not help, on current evidence, is bed rest, back braces and corsets, traction, or waiting for the pain to disappear entirely before moving normally again.
Painkillers, and what UK guidance says
The advice is narrower than most medicine cabinets suggest, and it has changed.
- Anti inflammatories
- NICE recommends considering an oral non steroidal anti inflammatory such as ibuprofen for low back pain, at the lowest effective dose for the shortest possible time, taking into account stomach, heart and kidney risks. A pharmacist can advise on whether they are suitable.
- Paracetamol alone
- Not recommended on its own for low back pain, following the 2016 NICE guideline. It may still be used alongside other measures or where anti inflammatories are unsuitable.
- Opioids
- Weak opioids are considered only for acute pain where anti inflammatories are unsuitable or ineffective. They are not recommended for chronic low back pain.
- Muscle relaxants and gabapentinoids
- Not recommended routinely for low back pain or sciatica in current UK guidance.
- Topical rubs
- Popular, cheap and low risk. The evidence for them in back pain specifically is modest, and comfort is a legitimate reason to use something.
Painkillers are a way of making movement possible, and that is the whole of their job in the first fortnight. Anyone taking anything daily for more than a couple of weeks should be talking to a pharmacist or a GP about it rather than quietly continuing.
Why a scan is usually the wrong first move
The instinct to want a picture is entirely reasonable and usually unhelpful. UK guidance advises against routine imaging for low back pain outside a specialist setting, and the reason is not cost.
Scans of people with no pain at all are full of findings. A well known review of imaging studies in symptom free adults found disc degeneration in about 37 per cent of thirty year olds and around 96 per cent of eighty year olds, with disc bulges present in roughly 30 per cent of thirty year olds rising to 84 per cent at eighty. In other words, most of what appears on an MRI report is the equivalent of grey hair: extremely common, strongly related to age, and a poor explanation for why a particular back hurts this month.
Being told about a bulging disc or degenerative change also has a measurable effect on how people recover. It tends to increase fear of movement, which is the opposite of what helps. Imaging becomes genuinely useful when it will change what is done next, which is why it follows a clinical assessment rather than preceding one.
When pain persists past twelve weeks
Pain lasting more than three months is usually described as chronic or persistent. It is a different problem from acute pain, not simply a longer one, and the approach shifts accordingly.
The most useful idea to carry into it is that persistent pain is a poor smoke alarm. The nervous system becomes more sensitive over time, so the alarm goes off at lower thresholds, and the volume of the pain stops being a reliable measure of the state of the tissue. That is not the same as saying the pain is imagined. It is real, it is generated by a real system, and it responds to different tools.
- Exercise is the backbone, and current UK guidance is refreshingly relaxed about which sort. Walking, swimming, strength work, yoga, tai chi and structured physiotherapy programmes all have supporting evidence. The best one is generally the one that will still be happening in six months.
- Pacing beats boom and bust. Doing everything on a good day and paying for it for three is the most common pattern in chronic pain and the most worth breaking. Setting a level that is sustainable on a bad day, then increasing it slowly, works better than it sounds.
- Psychological approaches are mainstream, not a consolation prize. NICE recommends acceptance and commitment therapy or cognitive behavioural therapy for chronic primary pain, and combined physical and psychological programmes for people with significant disability from back pain.
- Sleep is a lever, not a symptom. Pain disturbs sleep and poor sleep lowers pain thresholds, so the loop runs in both directions. Sleeping with persistent pain covers what tends to work.
- Medication has a smaller role than it used to. For chronic primary pain, NICE does not recommend starting paracetamol, anti inflammatories, opioids or benzodiazepines, and suggests antidepressants may be considered after discussion. This surprises people, and it reflects how modest the benefits proved to be against the harms.
Many areas of England allow self referral to NHS physiotherapy, and a growing number of GP practices have a first contact physiotherapist who can be seen directly. Asking the surgery what exists locally is often quicker than asking for a GP appointment.
Where manual therapy fits
Osteopathy, chiropractic, physiotherapy and massage all sit in the same place in UK guidance, which is a narrower place than their advertising suggests and a real one. NICE recommends that manual therapy, meaning spinal manipulation, mobilisation or soft tissue technique, may be considered for low back pain, but only as part of a treatment package that includes exercise, with or without psychological therapy. Hands on treatment on its own is not recommended.
That is a sensible way to read it in practice: manual therapy can buy enough comfort and confidence to make the active part possible, and the active part is what changes the following months. Anyone being sold a long course of treatment with no exercise component and no review point is being sold the wrong thing. What osteopathy involves in the UK, how the professions differ and what is actually available on the NHS are covered separately, including how to check a practitioner on a public register in about two minutes.
The symptoms that change the plan
A small minority of back pain has a serious cause. The symptoms below are the ones UK clinicians are trained to treat as urgent, and none of them belong in a waiting and seeing plan.
Get help today, not next week
Numbness or tingling around the back passage, genitals or inner thighs. Difficulty passing urine, or loss of bladder or bowel control. Numbness or weakness in both legs. Back pain with a fever, or with unexplained weight loss. Pain following a serious fall or accident. Severe pain that keeps worsening, particularly at night. New back pain in someone with a history of cancer, or in someone taking long term steroids. In the UK, contact a GP or call NHS 111 straight away, and 999 if symptoms are severe or come on suddenly. The first three on that list can indicate cauda equina syndrome, which is treated as an emergency because delay causes permanent damage.
It is also reasonable to book a routine GP appointment if pain has not begun to improve after six weeks, if it keeps returning every few months, or if it is stopping sleep or work. None of that is an emergency, and all of it is worth a conversation.
Common questions
How long should back pain take to improve?
Most episodes improve substantially within four to six weeks, with stiffness sometimes lingering longer. Sciatica is usually slower. Pain that has not started to shift at all by six weeks is worth a GP appointment, even though it is rarely sinister.
Is heat or ice better?
Heat has slightly better evidence for acute low back pain and most people find it more comfortable. Ice is more commonly useful in the first day or two after a clear injury. Neither changes the outcome much, so the sensible rule is to use whichever feels better.
Does a firmer mattress help?
Not necessarily. What evidence exists points towards medium firm rather than very firm, and personal comfort is the better guide. Replacing a mattress that visibly sags is worthwhile. Replacing a perfectly good one because of a back ache usually is not.
Can back pain be caused by stress?
Stress does not invent pain, but it reliably turns up the volume and raises resting muscle tension, and it is one of the better predictors of whether an episode becomes persistent. How stress and muscle tension interact is worth reading alongside the physical side.
Should exercise be stopped when the back hurts?
Rarely, and briefly if so. Reducing load for a few days is reasonable, stopping altogether is not. Something that hurts a little during and no more afterwards is generally safe. Something that leaves you worse for two days needs scaling back rather than abandoning.
Does gardening or lifting really trigger it?
Often, though usually as the last straw rather than the cause. An unaccustomed few hours of forward bending on a body that has been at a desk all week is a large change in load. The gardening page explains why the pain tends to arrive the following morning rather than at the time.