If you have an achy back, you’ve got company. As many as 80 percent of adults will have back pain. 
 
 Berta Axelrad, 76, has lived with chronic low back pain for most of her life. 
 
 “The pain is just so, well, it’s terrible!” she said. 
 
 She swears by exercise, yoga and walking. 
 
 “It minimizes the pain,” Axelrad said. “It’s not always easy, but it’s much better than doing nothing.” 
 
 New guidelines from the American College of Physicians say the first line of therapy should be non-drug treatments. For pain lasting less than three months, those include heat wraps, massage, acupuncture and spinal manipulation. The authors stress that clinicians should avoid costly and potentially harmful treatments like narcotics. 
 
 For pain lasting more than three months, treatments include stretching and strengthening exercises, tai chi, yoga, acupuncture, and mindfulness techniques like meditation to relieve stress. 
 
 If those fail, anti-inflammatories such as ibuprofen should be considered first, then medications that can dull nerve pain, like tramadol or duloxetine. 
 
 “Some of these treatments such as yoga or massage are often offered outside the traditional healthcare system,” said Dr. Steven Atlas of Massachusetts General Hospital, who wrote an editorial about the guidelines. 
 
 “Some of these guidelines may be a shot across the bow to insurers to say that maybe we should be covering them better,” Atlas said. 
 
 CBS Evening News 
 
 Hospital for Special Surgery physical therapist Dana Rose demonstrated some moves designed to bring relief. 
 
 “By activating and using your core muscles that should lessen the load through our joints to help minimize back pain,” she said. 
 
 The recommendation to use non-drug therapies first is especially relevant right now, when the country is facing an epidemic of opioid abuse. 

 Introduction 
 
 Low-back pain (often referred to as “lower back pain”) is a common condition that usually improves with self-care (practices that people can do by themselves, such as remaining active, applying heat, and taking pain-relieving medications). However, it is occasionally difficult to treat. Some health care professionals are trained to use a technique called spinal manipulation to relieve low-back pain and improve physical function (the ability to walk and move). This fact sheet provides basic information about low-back pain, summarizes research on spinal manipulation for low-back pain, and suggests sources for additional information. 
 
 Key Points 
 
 Spinal manipulation is one of several options—including exercise, massage , and physical therapy—that can provide mild-to-moderate relief from low-back pain. Spinal manipulation appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications. 
 
 , and physical therapy—that can provide mild-to-moderate relief from low-back pain. Spinal manipulation appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications. Spinal manipulation appears to be a generally safe treatment for low-back pain when performed by a trained and licensed practitioner. The most common side effects (e.g., discomfort in the treated area) are minor and go away within 1 to 2 days. Serious complications are very rare. 
 
 Cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, may be an extremely rare complication of spinal manipulation. However, it is unclear if there is actually an association between spinal manipulation and CES. 
 
 Tell all your health care providers about any complementary health practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care. 
 
 About Low-Back Pain 
 
 Back pain is one of the most common health complaints, affecting 8 out of 10 people at some point during their lives. The lower back is the area most often affected. For many people, back pain goes away on its own after a few days or weeks. But for others, the pain becomes chronic and lasts for months or years. Low-back pain can be debilitating, and it is a challenging condition to diagnose, treat, and study. The total annual costs of low-back pain in the United States—including lost wages and reduced productivity—are more than $100 billion. 
 
 About Spinal Manipulation 
 
 Spinal manipulation—sometimes called “spinal manipulative therapy”—is practiced by health care professionals such as chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and some medical doctors. Practitioners perform spinal manipulation by using their hands or a device to apply a controlled force to a joint of the spine. The amount of force applied depends on the form of manipulation used. The goal of the treatment is to relieve pain and improve physical functioning. 
 
 Side Effects and Risks 
 
 Reviews have concluded that spinal manipulation for low-back pain is relatively safe when performed by a trained and licensed practitioner. The most common side effects are generally minor and include feeling tired or temporary soreness. 
 
 Reports indicate that cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, may be an extremely rare complication of spinal manipulation. However, it is unclear if there is actually an association between spinal manipulation and CES, since CES usually occurs without spinal manipulation. In people whose pain is caused by a herniated disc, manipulation of the low back appears to have a very low chance of worsening the herniation. 
 
 For risks associated with spinal manipulation affecting the upper (cervical) spine, see the NCCIH fact sheet Chiropractic: An Introduction . 
 
 What the Science Says About Spinal Manipulation for Low-Back Pain 
 
 Overall, studies have shown that spinal manipulation is one of several options—including exercise, massage, and physical therapy—that can provide mild-to-moderate relief from low-back pain. Spinal manipulation also appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications. 
 
 In 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options for practitioners to consider when low-back pain does not improve with self-care. More recently, a 2010 Agency for Healthcare Research and Quality (AHRQ) report noted that complementary health therapies, including spinal manipulation, offer additional options to conventional treatments, which often have limited benefit in managing back and neck pain. The AHRQ analysis also found that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. However, the researchers noted inconsistent results when they compared spinal manipulation with massage or physical therapy to reduce low-back pain intensity or disability. 
 
 Researchers continue to study spinal manipulation for low-back pain. 
 
 A 2011 review of 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function. 
 
 A 2010 review that looked at various manual therapies, such as spinal manipulation and massage, for a range of conditions found strong evidence that spinal manipulation is effective for chronic low-back pain and moderate evidence of its effectiveness for acute low-back pain. 
 
 A 2009 analysis looked at the evidence from 76 trials that studied the effects of several conventional and complementary health practices for low-back pain. The researchers found that the pain-relieving effects of many treatments, including spinal manipulation, were small and were similar in people with acute or chronic pain. 
 
 A 2008 review that focused on spinal manipulation for chronic low-back pain found strong evidence that spinal manipulation works as well as a combination of medical care and exercise instruction, moderate evidence that spinal manipulation combined with strengthening exercises works as well as prescription nonsteroidal anti-inflammatory drugs combined with exercises, and limited-to-moderate evidence that spinal manipulation works better than physical therapy and home exercise. 
 
 Researchers are investigating whether the effects of spinal manipulation depend on the length and frequency of treatment. In one study funded by NCCIH that examined long-term effects in more than 600 people with low-back pain, results suggested that chiropractic care involving spinal manipulation was at least as effective as conventional medical care for up to 18 months. However, less than 20 percent of participants in this study were pain free at 18 months, regardless of the type of treatment used. 
 
 Researchers are also exploring how spinal manipulation affects the body. In an NCCIH-funded study of a small group of people with low-back pain, spinal manipulation affected pain perception in specific ways that other therapies (stationary bicycle and low-back extension exercises) did not. 
 
 Managing Low-Back Pain A review of evidence-based clinical guidelines for managing low-back pain resulted in several recommendations for primary care physicians and pointed to potential benefits of nondrug therapies including spinal manipulation, as well as exercise, massage, and physical therapy: Acute low-back pain: Routine imaging (x-rays or MRIs) generally is not necessary for patients who have had nonspecific low-back pain for a short time. These patients often improve on their own and usually should remain active, learn about back pain and self-care options, and consider nondrug therapies, including spinal manipulation, if pain persists longer than 4 weeks. 
 
 Routine imaging (x-rays or MRIs) generally is not necessary for patients who have had nonspecific low-back pain for a short time. These patients often improve on their own and usually should remain active, learn about back pain and self-care options, and consider nondrug therapies, including spinal manipulation, if pain persists longer than 4 weeks. Chronic low-back pain: Long-term use of opioid drugs usually does not improve functioning for patients with chronic low-back pain. However, these patients may benefit from nondrug therapies, including spinal manipulation. Psychological and social factors also may play a role in chronic low-back pain. Most patients will not become pain free; a realistic outlook focuses on improving function in addition to reducing pain. To learn more, see the NCCIH Research Spotlight. 
 
 NCCIH-Funded Research 
 
 Recent NCCIH-supported projects have been investigating: 

 Breaking News Emails Get breaking news alerts and special reports. The news and stories that matter, delivered weekday mornings. 
 
 / Updated By Maggie Fox 
 
 Patients with lower back pain should try heat wraps and exercise first, and prescription drugs should be used only as a last resort, a leading doctors' group said Monday. 
 
 New guidelines from the American College of Physicians detail just what works and what doesn't for lower back pain, which affects a quarter of Americans at any given time. 
 
 "Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat massage, acupuncture, or spinal manipulation," the American College of Physicians says in its new guidance. 
 
 A woman rubs her lower back. Tom Merton / Getty Images, file 
 
 It may be a big change for many doctors, who often turn to pills first for patients who are in pain. 
 
 "For patients with chronic low back pain, [the] American College of Physicians (ACP) recommends non-drug therapy first," the organization says in the new guidelines, published in the Annals of Internal medicine. 
 
 Heat wraps, massage and exercise can all help, the group said. 
 
 Related: Acupuncture Can Help Some Back Pain 
 
 "Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, and spinal manipulation are shown to improve symptoms with little risk of harm," it adds. 
 
 "ACP emphasizes that physical therapies should be administered by providers with appropriate training." 
 
 "Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies." 
 
 If none of those helps, then over-the-counter drugs such as ibuprofen or naproxen can be tried, the group says. Acetaminophen, the active ingredient in Tylenol, has been shown in several studies to do little to help back pain, it added. 
 
 Only if nothing else works and the patient is still in debilitating pain should a doctor try prescription drugs, the ACP says. 
 
 "Physicians should consider opioids as a last option for treatment and only in patients who have failed other therapies, as they are associated with substantial harms, including the risk of addiction or accidental overdose," said Dr. Nitin Damle, president of the ACP. 
 
 "Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients." 
 
 Monica Afesi of New York says yoga worked for her. 
 
 "I have had back pain for about 20 years, and it started off pretty mild," Afesi told NBC News. 
 
 "In their last six or seven years, it bothered me to the point where I had to go to chiropractors and get help that way," she said. "I have trouble bending over to feed my cats. I have trouble picking up my keys if I drop them at the door." 
 
 To her surprise, yoga helped. "If I'm feeling an onset of pain, I know I can come into class, take a class and every time I come into class and finish. I feel taller. I feel stronger. My spine feels longer." 
 
 That doesn't surprise Alison West, director of Yoga Union Back Care and Scoliosis Center in New York. 
 
 "The number one cause of lower back pain is poor posture and poor sitting," West told NBC News. 
 
 "If it works, you'll know relatively soon for low back pain." 
 
 The evidence backing yoga to help back pain is not strong. But there are many different types of yoga, and West said the instructor is important. 
 
 "We often hear people being told they should just do yoga to help their back, and that can be problematic, because we have had students come to us saying the yoga practice did increase their problem," she said. 
 
 "That is not necessarily the fault of the yoga. It was just the wrong practice at that time for the problem the student might have had." 
 
 Yoga should never hurt, West said. 
 
 "Pain should never be there, and in fact, our motto is 'no pain, no pain,'" she said. "No student should be forced into a pose." 
 
 West said patients should make sure yoga instructors are qualified and know about their back pain before they start. 
 
 Alternative therapies in general are worth trying, said Houman Danesh, director of Integrative Pain Management at Mount Sinai Hospital in New York. Evidence also backs the use of acupuncture. 
 
 "Overall, it's a very safe thing to at least try. And if it works, you'll know relatively soon for low back pain." 
 
 There is not enough evidence to show whether antidepressants, benzodiazepines (drugs that include Valium), anti-seizure medications or opioids even help lower back pain, the ACP said. 
 
 And there's some evidence showing that ultrasound and TENS (transcutaneous electrical nerve stimulation) do little or nothing to help, the ACP said. 

 Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said. 
 
 In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines. 
 
 “For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ” 
 
 Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin. 
 
 Scans, like an M.R.I., for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain. 
 
 Measures that help patients get back to their usual routines can help along the way, as Sommer Kleweno Walley, 43, of Seattle, can attest. Last spring, she slipped on the stairs in her house and fell down hard, on her back. 
 
 “After a couple of hours I could barely walk,” she said. “I was in real pain.” 
 
 She saw a physical therapist, but the pain persisted. Eleven days later, she showed up at the office of Dr. Christopher J. Standaert, a spine specialist at the University of Washington and Harborview Medical Center. She expected to receive an M.R.I., at least, and maybe a drug for pain. 
 
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 But Dr. Standaert told her an M.R.I. would not make any difference in her diagnosis or recovery and that the main thing was to keep active. She ended up getting anti-inflammatory medication and doing physical therapy. A few months later, her back stopped hurting. 
 
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 It is surprising, some experts in back pain say, how often patients are helped by treatments that are not medical, even by a placebo that patients are told at the start is really a placebo. 
 
 Dr. Standaert cited a study in which patients with chronic low back pain were offered a placebo, and were told it was a placebo, along with their usual treatment — often an anti-inflammatory drug like ibuprofen or naproxen. Or, the patients remained with their usual treatment alone. 
 
 Those taking the placebo reported less pain and disability than those in the control group who did not take it. The placebo effect, although modest, was about the same as the effect in studies testing nonpharmacological treatments for back pain like acupuncture, massage or chiropractic manipulations. 
 
 Many people with chronic back pain tend to shut down, avoiding their usual activities, afraid of making things worse, Dr. Standaert said. Helping them is not a matter of prescribing drugs but rather teaching them to set goals and work toward returning to an active life, even if they still have pain. 
 
 “They have to believe their life can get better,” Dr. Standaert said. “They have to believe they can get to a better state.” 
 
 The question is: Will the new guidelines be adopted? 
 
 “Patients are looking for a cure,” said Dr. Steven J. Atlas, a back pain specialist at Massachusetts General Hospital, who wrote an editorial accompanying the article on the new recommendations. “The guidelines are for managing pain.” 
 
 Added to the problem are the incentives that push doctors and patients toward medications, scans and injections, Dr. Deyo said. “There is marketing from professional organizations and from industry,” he said. “‘We have the cure. You can expect to be cured. You can expect to be pain free.’” 
 
 Medical insurance also contributes to the treatment problem, back experts say, because it does not pay for remedies like mindfulness training or chiropractic manipulations which, Dr. Deyo added, “are not cheap.” 
 
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 Even if doctors want to recommend such treatments, there is no easy referral system, Dr. Atlas said. 
 
 “It is much easier at Mass General to get a shot than to get a mind-body or cognitive behavioral therapy,” he added. 
 
 Dr. Weinstein has a prescription: “What we need to do is to stop medicalizing symptoms,” he said. Pills are not going to make people better and as for other treatments, he said, “yoga and tai chi, all those things are wonderful, but why not just go back to your normal activities?” 
 
 “I know your back hurts, but go run, be active, instead of taking a pill.” 

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– If you're tempted to pop a painkiller every time you feel a twinge coursing down your back, there's a new set of guidelines you may want to peruse first. Per NBC News and CBS News, prescription meds for lower back pain should be your go-to only when you've gone to every other option before them, according to the American College of Physicians' update. The guidelines, published in the Annals of Internal Medicine journal, instead advise to first try exercise, massages, heat therapy, acupuncture—even something called "spinal manipulation," which is controlled force applied to a joint in the spine by an experienced health care professional. Even more holistic approaches (including yoga, tai chi, and meditation) are encouraged over opioids for long-term aches. Dr. Steven Atlas, who wrote an accompanying editorial for the new guidelines, says they "may be a shot across the bow to insurers" to provide more coverage for these "alternative" treatments, per CBS. Not that the group is averse to all medications: It says anti-inflammatories like ibuprofen and naproxen can provide relief, though acetaminophen hasn't been shown to be terribly effective. The main goal is to keep people away from drugs that can get them hooked. "Opioids should be considered only if no other treatments work and only if there are more benefits than risks for an individual patient," the journal writeup notes. As for those with acute back pain (defined as lasting four weeks or less, without pain shooting through the leg), a spine researcher tells the New York Times that patients can often just wait it out with no physician intervention at all.