Straight answers about back soreness

Sources

1. The 2017 American College of Physicians guideline makes a STRONG recommendation that acute and subacute low back pain be treated first with non-drug care - superficial heat, massage, acupuncture or spinal manipulation - because most patients improve over time regardless of treatment, and a STRONG recommendation that chronic low back pain be treated first with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, EMG biofeedback, low-level laser therapy, operant therapy, cognitive behavioural therapy or spinal manipulation. Drugs are second, and opioids are a weak recommendation of last resort.

   Qaseem A, Wilt TJ, McLean RM, et al. — Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.. Annals of Internal Medicine, 2017. DOI: 10.7326/M16-2367.

2. A 2025 Cochrane overview of 31 Cochrane reviews covering 644 trials and 97,183 adults found that exercise therapies probably reduce chronic low back pain by 15.2 points on a 0-100 scale versus no treatment or usual care and improve function by 6.8 points, that multidisciplinary therapies probably produce a medium pain reduction, that acupuncture probably improves function only slightly versus sham, that traction is probably no different from sham traction, and that spinal manipulation probably makes no difference to function versus placebo in acute low back pain.

   Rizzo RR, Cashin AG, Wand BM, et al. — Non-pharmacological and non-surgical treatments for low back pain in adults: an overview of Cochrane reviews.. Cochrane Database of Systematic Reviews, 2025. DOI: 10.1002/14651858.CD014691.pub2.

3. The Cochrane review of exercise therapy for chronic low back pain pooled 249 trials and found moderate-certainty evidence of a clinically important 15.2-point pain reduction (0-100 scale) versus no treatment, usual care or placebo. The effect on functional limitations was 6.8 points, which did NOT meet the review's own threshold for a minimal clinically important difference, and adverse effects were mostly minor muscle soreness.

   Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW — Exercise therapy for chronic low back pain.. Cochrane Database of Systematic Reviews, 2021. DOI: 10.1002/14651858.CD009790.pub2.

4. A Cochrane review of 41 trials and 6,858 people with chronic low back pain of more than a year's duration found multidisciplinary biopsychosocial rehabilitation reduced pain and disability compared with usual care, and nearly doubled the odds of being at work a year later compared with physical treatment alone (OR 1.87). Two trials comparing it with surgery found little difference in outcomes and MORE adverse events with surgery.

   Kamper SJ, Apeldoorn AT, Chiarotto A, et al. — Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.. BMJ, 2015. DOI: 10.1136/bmj.h444.

5. A network meta-analysis of 97 randomised trials and 13,136 participants found psychological interventions for chronic low back pain work best when delivered ALONGSIDE physiotherapy care rather than instead of it: cognitive behavioural therapy and pain education with physiotherapy produced clinically important improvements in physical function, and behavioural therapy with physiotherapy was the only combination that maintained clinically important pain reduction to mid-term follow-up.

   Ho EK, Chen L, Simic M, et al. — Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis.. BMJ, 2022. DOI: 10.1136/bmj-2021-067718.

6. A meta-analysis of 35 placebo-controlled randomised trials found NSAIDs reduce spinal pain and disability, but by an amount below the threshold for clinical importance: six people must be treated with an NSAID rather than placebo for one additional person to achieve clinically important pain reduction, and NSAIDs raised the risk of gastrointestinal reactions 2.5-fold. The authors conclude that no simple analgesic provides clinically important effects for spinal pain over placebo.

   Machado GC, Maher CG, Ferreira PH, et al. — Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis.. Annals of the Rheumatic Diseases, 2017. DOI: 10.1136/annrheumdis-2016-210597.

7. High-quality evidence from 13 randomised trials shows paracetamol (acetaminophen) is INEFFECTIVE for low back pain: the weighted mean difference against placebo was -0.5 points on a 0-100 pain scale, with no effect on disability or quality of life, and patients taking it were nearly four times more likely to have abnormal liver function tests.

   Machado GC, Maher CG, Ferreira PH, et al. — Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials.. BMJ, 2015. DOI: 10.1136/bmj.h1225.

8. The SPACE trial randomised 240 patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain to an opioid or a non-opioid medication strategy for 12 months. Opioids were not superior on pain-related function, pain intensity was significantly BETTER in the non-opioid group, and medication-related adverse symptoms were significantly more common with opioids. The authors state the results do not support initiating opioid therapy for chronic back pain.

   Krebs EE, Gravely A, Nugent S, et al. — Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial.. JAMA, 2018. DOI: 10.1001/jama.2018.0899.

9. The OPAL trial randomised 347 people presenting with acute low back or neck pain to guideline care plus a short course of oxycodone-naloxone or guideline care plus an identical placebo. Mean pain at six weeks was 2.78 in the opioid group versus 2.25 in the placebo group - the opioid group did slightly WORSE, and the difference was not statistically significant. The authors call for a change in the frequent use of opioids for these conditions.

   Jones CMP, Day RO, Koes BW, et al. — Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial.. The Lancet, 2023. DOI: 10.1016/S0140-6736(23)00404-X.

10. The FDA states verbatim that stem cell products, stromal vascular fraction, umbilical cord blood, Wharton's jelly, amniotic fluid and exosome products have NOT been 'approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain.' No stem cell product is approved in the United States for any orthopedic use: the only ones with FDA approval at all are blood-forming cells derived from umbilical cord blood, approved solely for disorders of blood production, and there are currently no FDA-approved exosome products.

    U.S. Food and Drug Administration — Consumer Alert on Regenerative Medicine Products Including Stem Cells and Exosomes.. FDA.gov, 2025.