Chronic Back Pain

Why back pain becomes chronic

Most new episodes of back pain improve substantially within 6 weeks. In a minority, pain persists. Research shows the transition to chronic pain depends less on what scans show and more on:

• pain sensitization: the nervous system becomes more sensitive, amplifying signals from the back
• fear of movement and avoidance: resting and guarding lead to stiffness, weakness and more pain
• psychological factors: stress, low mood, anxiety and catastrophizing ("my back is crumbling")
• sleep problems
• work factors: heavy physical demands, low job satisfaction, and long time off work
• general health: smoking, obesity and low physical activity

This does not mean the pain is imaginary. It means that treatment needs to address the body and the nervous system together.

Causes

Nonspecific low back pain

About 85 to 90 in 100 people with back pain have no specific identifiable cause. Scans often show disc wear, bulges or facet arthritis, but these are also very common in people without any pain and increase with age. They rarely explain why one person hurts and another does not.

Specific causes

Rare but serious causes include spinal infection, cancer that has spread to the spine, and conditions outside the spine, such as kidney disease, aortic aneurysm, pancreatic disease and gynecological conditions.

Symptoms

• aching, stiffness or sharp pain in the lower or upper back
• pain that varies with activity, posture and time of day
• muscle spasms
• pain spreading to the buttocks or thighs
• leg pain, numbness or weakness when a nerve is involved
• tiredness, poor sleep and low mood, which commonly accompany chronic pain

Diagnosis

A doctor will take a detailed history, ask about red flags, and examine your back, hips, nerves (strength, reflexes, sensation) and walking.

• Imaging: X-ray, MRI or CT is not routinely needed for chronic nonspecific back pain. Guidelines recommend imaging only with red flags, progressive nerve problems, or when surgery or injections are being considered. Unnecessary scans often find harmless changes that increase worry without changing treatment.
• Blood tests for inflammation or infection if suspected.
• Questionnaires that screen for risk of persistent disability (such as the STarT Back tool) help match treatment intensity to need.

Treatment

Stay active and exercise

Exercise is the cornerstone of treatment. No single type is clearly best, so choose something you will keep doing:

• a structured program from a physical therapist (strengthening, flexibility, motor control)
• walking, swimming or cycling
• yoga, tai chi or Pilates
• graded activity: building up gradually despite some discomfort

Bed rest is not recommended.

Psychological and combined approaches

• Cognitive behavioral therapy (CBT) and pain reprocessing therapy help change how pain is processed and reduce fear and disability.
• Mindfulness-based stress reduction.
• Multidisciplinary rehabilitation combining exercise, education and psychological support, for severe or disabling pain.

Hands-on and other therapies

• Spinal manipulation or mobilization by a chiropractor, osteopath or physical therapist, as part of a broader plan
• Massage for short-term relief
• Acupuncture, recommended by some guidelines
• Heat for flare-ups

Medicines

• NSAIDs (ibuprofen, naproxen) are the first-choice medicine at the lowest effective dose for the shortest time. Avoid with stomach ulcers, kidney disease or heart failure.
• Duloxetine, an antidepressant that also reduces pain, is an option for chronic back pain.
• Acetaminophen (paracetamol) has little benefit for chronic back pain on its own.
• Opioids are not recommended for long-term use: benefits are small and risks of dependence, overdose and side effects are significant.
• Muscle relaxants, gabapentinoids and benzodiazepines are generally not recommended for chronic nonspecific back pain.

Procedures and surgery

• Epidural steroid injections can give short-term relief of sciatica from a disc herniation.
• Radiofrequency denervation of facet joints may help selected people after a positive diagnostic block.
• Surgery (discectomy, decompression) helps when there is a clear structural cause, such as persistent sciatica or spinal stenosis, that matches symptoms. Spinal fusion for nonspecific back pain has modest benefits and is rarely recommended outside clinical trials.

Living with chronic back pain

• Pace activities: alternate tasks, take short breaks, and avoid "boom and bust" cycles of overdoing it on good days.
• Keep working if possible, with adjustments. Long time off work makes recovery harder.
• Prioritize sleep and treat insomnia, which worsens pain.
• Stop smoking and aim for a healthy weight.
• Have a flare-up plan: heat, gentle movement, short-term NSAIDs, and keeping up light activity.

Frequently asked questions

What causes chronic back pain?

Most chronic back pain is nonspecific, with no single damaged structure responsible. It reflects sensitive spinal tissues, nervous system sensitization, deconditioning, sleep and stress. Specific causes include disc herniation, spinal stenosis, arthritis, inflammatory spine disease and, rarely, fractures, infection or cancer.

What is the best treatment for chronic back pain?

Exercise-based programs, physical therapy, yoga, tai chi, CBT and spinal manipulation have the best evidence. NSAIDs can help in the short term. Combining physical and psychological approaches works better than relying on medicines, injections or surgery for most people.

Do I need an MRI for chronic back pain?

Usually not. Guidelines recommend MRI only if you have red flag symptoms, significant or worsening nerve problems, or if surgery or injections are being considered. Many MRI findings, such as disc bulges, are common in people without pain.

Can chronic back pain go away?

Yes. Many people improve significantly or recover, even after months of pain. Staying active, building strength and confidence, and addressing sleep and stress improve the chances. Pain may flare at times, but flares usually settle.

When is back pain an emergency?

Back pain is an emergency if it comes with numbness in the groin or buttocks, new bladder or bowel problems, rapidly worsening leg weakness, high fever, or sudden severe pain with fainting. Call 911 or your local emergency number or go to an ER.