Back pain is one of the most common reasons people come to see me, and also one of the areas where I most frequently find myself explaining that the treatment a patient received elsewhere — or expects to receive — is not supported by the evidence.
Bed rest does not help. In fact, it tends to make back pain worse.
An MRI scan does not usually lead to better treatment. It often leads to findings that look alarming but are not the cause of the pain, and can lead to unnecessary intervention.
Surgery for most types of back pain has not been shown to be more effective than non-surgical treatment in the long term.
This is not nihilistic — there are effective treatments for back pain. But they are different from what many people expect, and the gap between evidence and practice remains significant.
What actually causes most back pain
The vast majority of back pain — approximately 85–90% — is what we call "non-specific low back pain." This means that no specific structural cause can be identified that fully explains the pain. This is often distressing for patients to hear: they want a diagnosis, a cause, a fix. But non-specific back pain is genuinely the most common presentation.
Common structural findings on scans — disc bulges, disc degeneration, facet joint arthritis, mild scoliosis — are extremely common in people with no pain at all. Large studies imaging pain-free volunteers have found disc bulges in up to 40% of 20-year-olds and over 80% of 50-year-olds. These findings are often incidental, not the cause of pain.
The biopsychosocial model: Modern pain science understands that pain is not simply a signal from damaged tissue. It is a complex output of the brain that is influenced by the tissue state, psychological factors (anxiety, depression, catastrophising, fear-avoidance beliefs), social factors (work satisfaction, social support, compensation and litigation), and past experience.
This does not mean the pain is "in your head" — it is absolutely real. It means that treating the tissue in isolation, without addressing psychological and social factors, tends to produce poor outcomes.
Case study: Tendai's MRI that led to fear
Tendai, 42, a civil engineer from Zimbabwe based in Bristol, developed sudden lower back pain after lifting. He saw his GP, who arranged an MRI. The report described: "L4/5 broad-based disc bulge with mild left foraminal narrowing, L5/S1 disc degeneration with mild annular fissure."
Tendai went home and Googled these findings. What he found terrified him. He became convinced he had serious spinal damage. He stopped exercising. He stopped lifting. He moved carefully and cautiously, convinced any wrong movement would worsen the damage. He took four weeks off work.
His pain got worse, not better.
When he came to see me, six weeks after the MRI, I explained what the findings actually meant: his scan showed changes common in men his age, essentially normal ageing, almost certainly present before his pain episode, and not the explanation for his acute pain. His deconditioning and fear-avoidance behaviour had created a cycle of pain, inactivity, muscle weakness, and more pain.
I referred him to physiotherapy. His physiotherapist progressively loaded his back — helping him rebuild confidence in his spine's ability to move and bear weight. He was back to full activity within 8 weeks.
"The scan made things worse," he told me, "not better."
This is an extremely common experience and illustrates why scans are not routinely recommended for non-specific back pain in the first 4–6 weeks.
What the evidence actually recommends
Stay active: The single most evidence-supported recommendation for acute non-specific back pain is to remain as active as possible, modify activities that significantly worsen pain, but avoid bed rest. Movement promotes healing, prevents deconditioning, and maintains the spinal structures that support the back.
Physiotherapy: For back pain that persists beyond a few weeks, physiotherapy — particularly exercise-based physiotherapy — has strong evidence. It should include active exercises, not passive treatments. Your physiotherapist should help you move, not just treat you.
Psychological approaches: For chronic back pain (lasting more than 12 weeks), cognitive behavioural therapy adapted for pain (CBT-pain or Pain Management Programmes) has strong evidence. It addresses catastrophising thoughts, fear-avoidance behaviour, and develops active coping strategies.
Medication: Simple analgesics — paracetamol and NSAIDs (ibuprofen if tolerated, check for kidney disease) — can help manage acute pain enough to stay active. They are tools to enable movement, not treatments in their own right. Opioids (codeine, tramadol) are generally not recommended for non-specific back pain — they are poorly effective for this type of pain and carry significant risks of dependency.
Spinal injections: Corticosteroid injections can provide temporary relief in specific circumstances (radicular pain — nerve root pain with clear dermatomal distribution) but evidence for long-term benefit is limited.
Surgery: For most types of non-specific back pain, surgery is not indicated and not more effective than non-surgical management in the long term. For specific structural problems — disc herniation with persistent severe neurological deficit, spinal stenosis with significant functional limitation — surgery may be appropriate after conservative treatment has been trialled.
When imaging is appropriate
MRI or CT scan for back pain is appropriate when:
- Red flag symptoms are present (see above)
- Neurological symptoms suggest nerve root compression (sciatic pain with weakness, numbness, or bowel/bladder involvement)
- Back pain fails to improve after 4–6 weeks of appropriate management
- Planning for surgery
- Suspicion of specific pathology (infection, malignancy, fracture)
Not appropriate when:
- Routine investigation of acute non-specific back pain within the first 4–6 weeks
- Reassurance seeking without clinical indication
What about the private sector?
A substantial industry has developed around back pain — private spinal clinics, chiropractors, osteopaths, massage therapists, acupuncture. Some of these have modest evidence for symptom relief (spinal manipulation for acute back pain; acupuncture for chronic back pain). Most lack evidence of modifying the underlying condition. The risk with expensive private interventions is that they encourage passive treatment-seeking rather than the active self-management that has the best long-term evidence.
If you are seeing a private practitioner: they should be helping you move and take responsibility for your own recovery, not creating dependency on their treatment.
Sources: NICE Clinical Guideline NG59 — Low Back Pain and Sciatica (2016, updated 2023); Brinjikji W et al, American Journal of Neuroradiology 2015 (MRI findings in asymptomatic adults); Waddell G, The Back Pain Revolution 2004; Main CJ et al, The Lancet 2008 (biopsychosocial model); Deyo RA et al, NEJM 2001 (lumbar spine surgery outcomes).