A woman stretching, which can help with back pain.

A ching lower backs, either acute or chronic, affect nearly half of healthy, active people older than 60, according to a February study in the Journal of the American Geriatrics Society.

More on Pain Relief

“Lower back pain is one of the most common pain problems for older adults and one of the most frustrating because there are no easy fixes,” says Roger Chou, M.D., a professor of medicine at Oregon Health & Science University in Portland.

Traditional treatments such as opioid pain pills, steroid injections, and surgery are not necessarily very effective and can have significant downsides.

But some good evidence supports certain nondrug and nonsurgical options. That’s why 2017 guidelines from the American College of Physicians (ACP) recommend them—and suggest drugs or surgery only when other therapies fail.

That advice is backed up by a nationally representative Consumer Reports survey of 3,562 back-pain sufferers.

More than 80 percent who tried yoga or tai chi, massage therapy, or chiropractic said it had helped them, as did more than 60 percent of respondents who tried acupuncture or physical therapy.

But experts agree that a personalized plan is best. “Everyone responds to pain differently,” says Jack Ende, M.D., immediate past president of the ACP.  “And what works for one person may fall flat in another.” 

So which steps should you take when your back starts aching, and in what order? Here’s what the research and our experts recommend.

When Back Pain First Strikes

Back pain is considered acute when a new episode lasts for less than four weeks. If your back begins to hurt, experts suggest starting with the following:

Heat or ice. For instance, a warm shower, hot-water bottle, or heating pad can reduce pain. Ice may also feel good.

Gentle activity. It’s best to resume normal activity. (If you can’t, walk for a few minutes every few hours, Ende says.) If you’re able, try easy stretches. A 2017 Cochrane Collaboration review found that people with back pain who were told to stay somewhat active reported less discomfort and recovered faster than those advised to stay in bed.

OTC pain relievers if needed. While the ACP emphasizes nondrug measures, Ende says over-the-counter ibuprofen (Advil or generic) or naproxen (Aleve and generic) can be used for a week or two.

If You're Still in Pain After a Week or Two

If you still have a lot of pain at this point, your doctor may provide a home-based exercise program or refer you to physical therapy for supervised exercise. (Some sessions are usually covered by insurance.)

PT may include massage or low-level laser therapy, but the exercise component is key. People who get PT within 90 days of the onset of pain get fewer imaging tests and questionable treatments, according to a study published in 2015 in the journal BMC Health Services Research.

After a month or two, you may feel well enough to get back to—or start—a normal exercise program.

And that’s important: People who have had lower back pain but are active are about one-third less likely to see it recur, according to a review published in 2017 in the American Journal of Epidemiology.

When Pain Persists for Months

For pain that continues even after a couple of months of home-based exercise or PT, the ACP recommends considering these (some may be covered by insurance):

Yoga and tai chi. They strengthen core muscles, relieving pressure on your back, says Benjamin Kligler, M.D., national director of the Integrative Health Coordinating Center for the Veterans Health Administration.

A 2017 Cochrane review of studies concluded that yoga improved back function. And research used as a basis for the ACP guidelines found that tai chi was useful for chronic back pain. It can also help with shorter-term pain, but it may take several weeks for you to see results, Kligler says.

Your doctor may be able to refer you to a local class for yoga (opt for a gentle form) or tai chi. YMCAs and fitness centers may also offer them.

Or find a list of certified instructors through the American Tai Chi and Qigong Association, the Yoga Alliance, or the International Association of Yoga Therapists.

Cognitive behavioral therapy or mindfulness-based stress reduction. If back pain has you feeling depressed or anxious, CBT—which focuses on circumventing negative thought patterns—may help. MBSR increases awareness and acceptance of pain with practices such as yoga and meditation.

Adults with chronic back pain who did either technique for 2 hours a week for eight weeks reported significant relief, according to a study published in 2016 in the Journal of the American Medical Association. Ask your doctor for the names of cognitive behavioral therapists, or check the website of the Association for Behavioral and Cognitive Therapies.

Spinal manipulation. Used by chiropractors, osteopaths, physical therapists, and some massage therapists, it involves moving the joints of the spine. A review published last year in JAMA found that spinal manipulation significantly improved pain and function for those with acute lower back pain. A Cochrane review concluded that it works as well as exercise, PT, or standard medical care for chronic back pain.

Check your health insurer’s website for licensed chiropractors and doctors of osteopathic medicine (D.O.), then ask your primary care doctor for a referral. (Our survey found that spinal manipulation is more likely than most nondrug treatments to be covered by insurance, at least partly.) Roger Chou at Oregon Health & Science University advises trying it for three to four weeks but moving on if it’s not helping.

Acupuncture. This involves inserting very fine needles into specific points on the body. “I usually have people with chronic back pain try a course of PT because it’s usually covered by insurance, and if that doesn’t seem to help, recommend they try acupuncture for six to eight sessions,” says Joseph Herrera, D.O., system chair for rehabilitation medicine at the Mount Sinai Health System in New York.

A large review of studies found that acupuncture outperformed sham treatment and no treatment for all kinds of chronic pain, including back pain. But it may cost you $100 or more per session. Make sure any acupuncturist you see is licensed by the state. Find listings on the National Certification Commission for Acupuncture and Oriental Medicine’s website.

What About Meds and Surgery?

If none of the above help or you’re in significant pain while starting a treatment like PT, a week or two of medication is reasonable, Chou says. The ACP recommends over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.

If you can’t take an NSAID or need stronger relief, consider the prescription pain pill tramadol (Ultram and generic) or the antidepressant duloxetine (Cymbalta and generic). Both have only a small effect on back pain, so you’ll need nondrug methods as well.

The nerve-pain drug gabapentin (Neurontin, Gralise, Horizant, and generic) is often prescribed for muscle pain, but research suggests that it’s not very effective and causes side effects such as dizziness.

And groups such as the ACP and the American Academy of Family Physicians strongly advise against the use of opioid painkillers such as oxycodone (Oxycontin and generic).

“These drugs are very problematic in seniors because they increase the risk of falls, as well as other concerns such as addiction and overdose,” Chou says.

Should surgery ever be an option? Only for persistent pain, numbness, and tingling that radiates down a leg from a herniated disk; severe or progressive weakness in a foot or leg; or spinal stenosis that hasn’t responded to therapies such as PT, Ende says. Even then, you can hold off if you’re seeing improvement.

Imaging Tests: When to Consider, When to Skip

You may be tempted to run to your doctor and request an X-ray or MRI for back pain. But that’s rarely helpful.

“One of the biggest misconceptions about these screening tests is that we can easily ID the cause from them,” says Richard Deyo, M.D., M.P.H., a professor of evidence-based medicine at Oregon Health & Science University. “The reality is, older adults usually have something that shows up on an X-ray or MRI, like worn-out or bulging disks. But oftentimes that’s not the cause of the problem.”

Consider imaging if you’ve had pain for six weeks and it’s not getting better, Deyo says. In that case, a pinched nerve may be contributing to the problem.

You should also contact your doctor immediately for an imaging test if you have back pain along with unexplained weight loss, a fever higher than 102° F, loss of bowel or bladder control, loss of strength or numbness in one or both legs, or a history of cancer. These may be signs of nerve damage, infection, or a tumor.

Editor’s Note: This article also appeared in the June 2018 issue of Consumer Reports On Health