Back Pain

For low back pain, guidelines start with non-drug care such as heat, exercise, massage, acupuncture or spinal manipulation, once warning signs are ruled out. The evidence for each is modest. Yoga, tai chi and mindfulness are options for chronic pain.

When to see a medical doctor first

These warning signs come from MedlinePlus and the American Academy of Family Physicians, with a few extra items from the NHS.

• Go to an emergency department now: new loss of bladder or bowel control or trouble passing urine; numbness in the groin, buttocks or inner thighs; or leg weakness or numbness that is getting worse. These can be signs of cauda equina syndrome, which is a medical emergency (AAFP). Don't wait for a routine appointment.
• Contact a clinician promptly: back pain with unexplained fever; pain after a severe blow or fall; a history of cancer; pain that wakes you at night; pain that travels down the leg below the knee; or trouble walking or keeping your balance.
• Also on the NHS list: back pain with chest pain needs emergency care (call 911). See a doctor for unexplained weight loss, a lump or change in the shape of the back, pain worse when coughing or during a bowel movement, or pain in the upper back.

If pain runs down the leg, see our page on sciatica.

What a medical workup usually checks first

The American College of Physicians' 2017 guideline covers back pain without nerve-root symptoms (ACP 2017). It makes a strong recommendation for non-drug treatment first:

• Acute or subacute pain: superficial heat (moderate-quality evidence), or massage, acupuncture or spinal manipulation (low-quality evidence). If medicine is wanted, NSAIDs or a muscle relaxant (moderate-quality evidence).
• Chronic pain: exercise, multidisciplinary rehabilitation, acupuncture or mindfulness-based stress reduction (moderate-quality evidence), or tai chi, yoga, CBT, progressive relaxation or spinal manipulation (low-quality evidence).
• Chronic pain that doesn't respond well enough: NSAIDs first, then tramadol or duloxetine. This is a weak recommendation based on moderate-quality evidence.

Imaging such as an X-ray or MRI is usually not needed for back pain without warning signs, because most episodes improve within weeks. Unless there are nerve deficits or other red flags, imaging does not improve outcomes (AAFP 2023; ACR Appropriateness Criteria 2021).

What the evidence says about holistic options

Therapy	Evidence	Notes
Yoga, tai chi, MBSR	Supported	ACP options for chronic low back pain: mindfulness-based stress reduction on moderate-quality evidence, yoga and tai chi on low-quality evidence. A 2022 meta-analysis of 27 studies showed short-term gains (NCCIH).
Chiropractic or spinal manipulation	Mixed/limited	Small improvements in pain and function (NCCIH). An ACP option for acute and chronic pain, on low-quality evidence. The VA/DoD 2022 guideline weakly suggests it for chronic pain and finds too little evidence to recommend for or against it in acute pain. Serious harms are very rare.
Acupuncture	Mixed/limited	An ACP option on low-quality evidence for acute pain and moderate-quality evidence for chronic pain. Small benefit compared with no treatment, minimal compared with sham (AFP summary).
Massage	Mixed/limited	An ACP option for acute and subacute pain, on low-quality evidence. NCCIH rates the evidence as weak and short-term.
Naturopathic or functional medicine	Unconfirmed	No source found.
Supplements	Unconfirmed	No source found.

Unconfirmed means we found no source in this review. It is not a verdict either way. Mild soreness, stiffness or headache after manipulation is common and usually resolves within 24 hours.

Who people see for back pain on this site

• Chiropractors, osteopaths and physical therapists. The VA/DoD guideline notes all three are trained in spinal manipulation.
• Acupuncture clinics and massage therapists.

Medicare pays for chiropractic only for manual manipulation of the spine to correct a subluxation, and not for maintenance care (CMS). For visit numbers and coverage, see our guides on how often to see a chiropractor and whether Medicare covers acupuncture.

Questions to ask a practitioner

• How do you screen for warning signs such as leg weakness or bladder changes, and when do you refer for imaging or to a physician?
• Which of your options have evidence for this type of back pain, and how many visits should a first course take?
• If you use spinal manipulation, what is the plan if symptoms get worse?

Last reviewed: October 2026

Sources

• MedlinePlus, Low back pain - acute (reviewed 27 June 2026)
• American Family Physician, Diagnosis and treatment of acute low back pain (February 2012)
• American Family Physician, Common questions about chronic low back pain (May 2015)
• American Family Physician, Practice guidelines: low back pain (2023)
• American College of Radiology, ACR Appropriateness Criteria: low back pain (2021 update)
• NHS, Back pain (reviewed 5 March 2026)
• American College of Physicians, Noninvasive treatments for low back pain (February 2017); AFP summary (September 2017)
• VA/DoD, Low back pain clinical practice guideline (February 2022)
• NCCIH, Spinal manipulation: what you need to know (September 2022)
• NCCIH, Yoga for pain (September 2024)
• CMS, Medicare Benefit Policy Manual, chapter 15 (July 2026)