Chronic Back Pain Treatment Options

What counts as chronic back pain?

Pain is generally called chronic when it persists beyond 12 weeks. Low back pain is one of the most common reasons adults visit a clinician — and most episodes improve, though a meaningful share become long-lasting.

Chronic low back pain can arise from many sources: muscle and ligament strain, degenerative disc changes, arthritis of the small spinal joints (facet joints), nerve root compression, or sometimes no single identifiable structural cause. Understanding the likely source guides treatment, which is why a careful evaluation matters before jumping to advanced imaging or procedures.

What treatments have the strongest evidence?

A 2017 clinical practice guideline from the American College of Physicians reviewed the evidence and recommends starting with non-pharmacologic (non-drug) approaches for both acute and chronic low back pain 1Ref 1Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017).Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.First-line recommendation for non-pharmacologic treatments for chronic low back pain, including exercise, physical therapy, and spinal manipulation. The American Physical Therapy Association's 2021 clinical practice guideline reinforces this, emphasizing active, movement-based care 2Ref 2George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS (2021).Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021 — Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association.APTA clinical practice guideline emphasizing active, movement-based care for chronic low back pain.

Exercise therapy is the most consistently supported intervention. A Cochrane review found that exercise reduces pain and improves function in people with chronic low back pain compared to minimal or no treatment 3Ref 3Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW (2021).Exercise therapy for chronic low back pain.Exercise therapy reduces pain and improves function in chronic low back pain. No single type of exercise is clearly superior — the best program is one you will do consistently. Options include:

• Supervised core stabilization or general strengthening
• Yoga and tai chi (evidence supports both for chronic low back pain)
• Walking programs
• Aquatic exercise, particularly for those with joint limitations

Physical therapy builds on exercise by adding manual therapy (hands-on joint mobilization), education about movement patterns, and a home program. The ACP guideline specifically recommends physical therapy as a first-line option 1Ref 1Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017).Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.First-line recommendation for non-pharmacologic treatments for chronic low back pain, including exercise, physical therapy, and spinal manipulation.

Mind-body approaches — including mindfulness-based stress reduction and cognitive behavioral therapy (CBT) — have meaningful evidence for reducing pain and disability in chronic pain. They work partly by changing how the brain processes pain signals 4Ref 4Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A (2012).The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses.CBT and mind-body approaches have evidence for reducing pain and improving function in chronic pain conditions.

Spinal manipulation (performed by chiropractors or physical therapists trained in manipulation) is supported as an option for some patients with low back pain in the ACP guideline 1Ref 1Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017).Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.First-line recommendation for non-pharmacologic treatments for chronic low back pain, including exercise, physical therapy, and spinal manipulation.

Acupuncture has been shown to reduce pain in people with chronic back pain in a large individual-patient data meta-analysis 5Ref 5Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K; Acupuncture Trialists' Collaboration (2018).Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis.Acupuncture reduces pain in chronic back pain based on individual patient data meta-analysis.

What role do medications play?

When non-drug approaches are not enough, medications may be added — but they are generally considered second-line for chronic low back pain, not the starting point.

• NSAIDs (like ibuprofen) are commonly used for flares 6Ref 6MedlinePlus / U.S. National Library of Medicine (2024).Ibuprofen: MedlinePlus Drug Information.NSAIDs like ibuprofen are used for back pain flares with awareness of risk profile. They carry risks with long-term use, including stomach and kidney effects.
• Acetaminophen may help some patients, though evidence for chronic back pain specifically is more limited 7Ref 7MedlinePlus / U.S. National Library of Medicine (2024).Acetaminophen: MedlinePlus Drug Information.Acetaminophen as an option for pain management with attention to dosing limits.
• Muscle relaxants are sometimes prescribed for acute episodes.
• Duloxetine (an SNRI antidepressant) has evidence for chronic musculoskeletal pain.
• Opioids are not recommended as first- or second-line treatment for chronic low back pain due to risks of dependence and limited long-term benefit.

A clinician can help weigh which, if any, medication fits your situation and health history.

When is imaging or a procedure warranted?

Most imaging (X-rays, MRI) does not change treatment for uncomplicated chronic low back pain and is not recommended routinely. Imaging is appropriate when there are "red flag" signs (see safety box below) suggesting a more serious cause.

Procedures such as epidural steroid injections, nerve blocks, or radiofrequency ablation may benefit specific patients — particularly those with confirmed nerve root compression or facet joint pain — but are generally reserved for those who have not responded to conservative treatment. Surgery is considered for a small subset of patients with structural causes (such as lumbar spinal stenosis or disc herniation causing nerve symptoms) that have not responded to at least six weeks of other treatment.

How does Gale help with chronic back pain?

A Gale primary care clinician can evaluate your back pain, review your history, order imaging when it is warranted, and coordinate a treatment plan that may include a referral to physical therapy, a pain specialist, or a spine surgeon. We can also help you track symptoms over time and adjust the plan as you progress.

If your pain has a significant impact on your mood or sleep — which is common — we can address those dimensions together or connect you with a behavioral health clinician.