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Chronic Back Pain: Relief and Prevention

Abbreviations / definitions ACP

American College of Physicians

BackCare

The National Back Pain Association

CNS

Central Nervous System (brain and spinal cord)

ICB

Integrated Care Board (NHS England divisions)

JAMA

The Journal of the American Medical Association

LBP

Low back pain

MSK

Musculoskeletal

NHS

National Health Service

NICE

National Institute for Health and Care Excellence, UK

StatPearls company

A professional healthcare education and technology

WHO

World Health Organisation

Booklets made available by BackCare are provided for information only and should not be considered as a medical recommendation or advice. BackCare is not responsible for errors or omissions in the information. Please consult your GP or Specialist to discuss any specific concerns or if you are considering changing treatment in any way, eg adding dietary supplements. © BackCare 2026

Contents Introduction .......................................................................................... 1 What is pain? ..................................................................................... 1 Back to back pain ............................................................................... 4 A quick tour of the spine ..................................................................... 5 Some common causes of LBP............................................................. 6 Dealing with LBP .................................................................................... 7 Medication ........................................................................................ 9 Stay active ......................................................................................... 9 Mindset ............................................................................................10 What about lifestyle? .........................................................................11 What can happen? ............................................................................11 Treatments .......................................................................................12 Prevention ............................................................................................19 Exercise (being active!) ......................................................................19 Posture / Movement ..........................................................................20 Relaxing ...........................................................................................21 Sleeping ...........................................................................................23 Handheld Devices .............................................................................24 Weight and Diet ................................................................................25 Smoking ...........................................................................................25 At Work ............................................................................................26 Workplace adjustments ....................................................................26 Lifting / Manual Handling ...................................................................27 Chairs / Workstations ........................................................................28 Conclusion ...........................................................................................30

Introduction BackCare is a registered charity providing information and education aimed at preventing unnecessary back pain and injuries from occurring along with giving support to related research projects. Operating for over 50 years, BackCare is an independent charity and receives no public funding, relying only on the generosity of donors, fund raisers and those leaving legacies. Our website (www.backcare.org.uk) is a good starting point for finding information about all matters back-related. Check out the “Back or Neck Pain” menu for a wide range of resources and external links including the BackCare Awareness Programme section. Here, you will find a range of information on conditions, treatments and prevention including links to many of the booklets we produce as a part of the Back Care Awareness Week each October. You can also find our resources online at www.ISSUU.com/backcare. For Back Care Awareness Week, 2026 this booklet sets out to look at chronic pain – with the spotlight on low back pain. After a brief overview of chronic pain, we examine some ways to deal with LBP including various treatments, all in the hope of helping those suffering from this debilitating condition to find some relief. The other main part of the booklet looks at preventing back pain – we think a lot of the information here could also be of use to those already in pain! Whatever the state of your back, we hope that you will find some useful ideas here for maintaining or improving the health of your spine. If you find this booklet useful, and are in a position to do so, we would be grateful if you might consider donating to BackCare via our website: https://backcare.org.uk

What is pain? When talking about back pain, perhaps we should start with pain in general. How pain is really experienced within the nervous system is very difficult to explain medically but we all know the agony of stubbing our toes or touching something hot. This is “acute” pain, usually short1

term and acting as a warning signal of actual or impending damage! This essential “alarm system” consists of receptors (on the skin and in joints, for example) that are triggered by some intense stimulus into sending signals through nerves, that are then transmitted up the spinal cord and into the brain. As part of this process, an injury can cause the immune system to trigger inflammation. In terms of acute tissue damage, this very complicated inflammatory mechanism will help to clear it, bringing oxygen and nutrients to the area and starting the repair process. Once the resulting tissue damage has repaired, this system should return to a baseline state where no pain is experienced. Chronic pain is longer lasting. In the medical world, the term ‘chronic’ simply means that the pain has persisted for a while. In terms of low back pain, the source of this persistent pain can sometimes be traced to a particular component(s) of the spine, sadly, more often this is not the case. Frustratingly, the cause of your chronic pain might never be identified but that does not necessarily prevent successful management. Chronic pain often loses its protective value to the body over time and is no longer a definite indicator of damage. (The British Pain Society 2026) One of the possible ways that chronic pain develops, is when the central nervous system (CNS) becomes more efficient at processing signals. From small beginnings, the signals amplify through the network (a bit like a Mexican wave in a football stadium, except the pain carries on) – the nervous system has become over sensitive. This is very far from the mechanism of acute pain described above. Another aspect of chronic pain is that it can be classified as primary or secondary. The primary classification means that there is no clear cause for the pain whereas secondary means that there is an identifiable cause. An example of secondary pain is neuralgia. This occurs where there is compression, irritation or damage to the nerves themselves leading to a sudden electric-shock type of pain. Examples are nerve damage after shingles or nerve injury caused by diabetes. To 2

be clear, when we talk about chronic pain in this booklet it will be mostly about primary pain. Research shows that men and women often experience pain in different ways, although the reasons are complex and not fully understood. On average, women report pain more often, feel it more intensely, and are more likely to develop certain long-term pain conditions such as migraines, fibromyalgia, and irritable bowel syndrome. Women also tend to have more active immune responses, which can increase inflammation and sensitivity. Men, on the other hand, are more likely to experience pain linked to injury or physical strain, and social expectations sometimes encourage them to under-report pain or “push through” discomfort. These differences are shaped not just by biology but also by psychology and society. Stress, trauma, cultural expectations, and access to support all influence how pain is felt and expressed. Understanding these patterns helps explain why chronic pain can look very different from person to person. So, pain is very much a personal experience; it can be strongly interlinked with emotion and personal circumstances. Feelings of anxiety, hopelessness or depression, as examples, can make the experience of pain worse. Conversely, feeling positive or happy can be of great benefit in coping and so restoring normality. Chronic, primary pain is a vastly complicated subject. Research shows that this type of pain can arise from many sources, such as: inherited traits, early experiences that shape the developing nervous system, long-term stress, immune activity, hormonal changes, and the way the brain interprets signals from the body – the list could go on. These influences can interact and amplify each other, making the pain feel very real even when scans and tests look normal. For example, research has shown that the amplified CNS pain described above can be experienced more severely when accompanied by mood problems such as depression. 3

Understanding this complexity helps explain why chronic pain can be so difficult to treat — and why any care programme often needs to address the whole person.

Back to back pain Across large epidemiological reviews (WHO, JAMA, StatPearls), it can be shown: •

Approximately 10% of low back pain cases have a specific, identifiable cause, some examples being: • • • •

• • •

lumbar radiculopathy (nerve root problem usually in the lumbar spine) spinal stenosis (narrowing of the canals and openings where nerves are) vertebral fracture axial spondyloarthritis (a type of immune-mediated arthritis primarily affecting the spine that often starts in the young – especially males) infection malignancy structural disc herniation with clear nerve compression

These “specific” causes are rare, typically 5–10%, and the serious causes (fracture, infection, malignancy) are <1% (Cashin 2026). However, it is important to rule out specific spinal conditions and serious illness if your symptoms are severe, something that your GP should be able to help with. To learn more about specific spinal conditions, go to the BackCare website, navigate to the “Back or Neck Pain” menu and click on “Conditions”. Therefore, that leaves 90% of low back pain (LBP) classified as nonspecific or idiopathic. This means that no single anatomical structure can be confidently identified as the source of the pain. Multiple structures in the spine can generate similar pain signals. This is why many guidelines (WHO, NICE, ACP) discourage routine imaging unless there are symptoms indicating a serious problem. Indeed, MRI imaging 4

has shown that disc degeneration is quite common (particularly in aging populations) in people who don’t experience back pain. As an aside, when reading articles about back pain, you might find the following standard, medical definitions useful. “Acute” is accepted to mean a pain lasting up to 6 weeks or showing significant improvement by then. “Subacute” means 6 to 12 weeks and “chronic” is lasting over 12 weeks. Treatments for these different types of back pain can be very different, more about this below.

A quick tour of the spine To help talk about back pain, it might be useful to give a quick overview of the structure of the spine. In simple terms, it consists of: numerous bones called vertebrae that have a hollow core carrying nerves; muscles, tendons, ligaments (providing connection, support and movement); and squashy discs (the ‘shock absorbers’ between the vertebrae). These together form a very strong, flexible and complex structure; any of its components can be responsible for back pain. Referring to the diagram below, the spine is divided into five sections with different characteristics and functions. From top to bottom, we start with the cervical spine running from deep in the skull and down through the neck which then connects to the thoracic spine (where ribs are attached), on into the lumbar spine and finally the sacrum and the coccyx where the vertebrae are fused together. When viewed from the side, the spine is not a straight line but more like four gentle curves, two facing inwards and two outwards. These curves help to keep an upright posture and at the same time provide flexibility and a range of movement. The cervical and lumbar regions curve inwards away from the front of the body (lordosis) and the thoracic and sacrum curve outwards towards the front of the body (kyphosis).

In simple terms, the cervical and lumbar regions allow for flexibility and movement whereas the thoracic and sacral regions provide stability and weight transfer. Importantly, the areas of greatest flexibility are also the ones prone to injury.

Figure 1: The Spine

Some common causes of LBP As we’ve already said, it’s important to remember that most low back pain is non-specific and acute (using the definition above). An overstretched muscle, a ruptured ligament or a pinched nerve (sometimes a combination) are common causes of acute back pain. It is often very difficult to pinpoint exactly where the pain comes from 6

and, in most cases, X-rays, MRI scans or other medical imaging tests do not provide any real insights into the origin of the pain. This is why your doctor might only refer you for X-rays and MRI scans in exceptional circumstances. If you do not respond to the first, simple steps described in the “Dealing with Pain” section below, then a visit to the GP is advisable. Remember that new episodes of low back pain that don’t get better can, in rare cases, hide a serious underlying condition. Back pain is most commonly felt in the lower back (the lumbar spine is flexible but more likely to suffer injury) and sometimes also spreads into the upper legs. Similarly, when the pain is higher up in the back, this can extend to the arms. This radiating pain can be caused when a nerve connected to your legs or arms is trapped in the back, for example by a bulging disc. A common condition, where the nerve is irritated or squashed as it leaves the spinal canal in the lower back, is known as ‘sciatica’. Sufferers experience more widespread pain that often includes the buttocks and the top of the leg(s). It is important to make sure that this is not the cause of your pain, before starting vigorous exercise. Check with your GP, who might want to do some tests or keep an eye on the situation. In very rare cases people experience weakness or reduced feeling in their legs and genital area or even bladder and bowel problems. If this is the case, you should seek medical advice immediately.

Dealing with LBP The 2026 JAMA review, mentioned above, drawing on 108 publications, (Cashin 2026) as well as guidelines from WHO, ACP and NICE, suggests that non-specific LBP is generally self-limiting. There are usually many things you can do to manage your back pain without specialist medical treatment and by following the advice below, you’ll probably find that you can cope with your pain and, 7

indeed, a lot of people do recover quickly. Clearly, a quick recovery is not always the case and your journey to managing chronic LBP could be longer and take determination. Although statistically unlikely, it is important to know that new episodes of back pain can be an indicator of a serious underlying condition. We recommend that you are aware of the following NHS guidelines: Make an appointment to see your GP if: •

back pain does not improve after treating it at home for a few weeks

•

the pain is severe or getting worse over time

Ask for an urgent GP appointment or call 111 if: You have back pain and: •

a high temperature

•

you’ve lost weight without trying to

•

there’s a lump or swelling in your back or your back has changed shape

•

the pain does not improve after resting or is worse at night

•

the pain is made worse when sneezing, coughing or opening your bowels

•

the pain is coming from the top of your back (between your shoulders), rather than your lower back

Call 999 or go to A&E if: You have back pain and: •

pain, tingling, weakness or numbness in both legs

•

numbness or tingling around your genitals or buttocks 8

•

difficulty passing urine

Medication When first experiencing new back pain, simple over-the-counter painkillers can be very helpful in keeping back pain under control and allowing you to remain active. Paracetamol is often recommended as the first choice of medication for back pain. If this does not help you, non-steroidal antiinflammatory drugs (NSAIDs) such as ibuprofen may provide relief (they are the most effective short-term drug ) but they are not suitable for everyone. (Cashin 2026) Other health conditions and drugs you are taking can cause problems – if in doubt ask your pharmacist or GP. If over-the-counter painkillers are not giving you sufficient pain relief, you can ask your GP for other options since recommendations do change. Remember that many pharmaceuticals can have side effects or negative implications. Read more about drugs in the Drugs for Pain Relief section in Treatments below.

Stay active Although you may feel like sitting still or even going to bed when back pain strikes, research has shown that inactivity can lead to longer recovery times. The advantage of pain relief is that it can help you to maintain movement – something which is so important in making a quick recovery. Do remember the NHS advice in the section above, however, and seek help if you are worried. If you are experiencing chronic pain, it’s still important to stay active but using medication for pain relief is more complicated. As a general principle, some drugs for pain relief can become less effective over time – others might have an addictive quality. GPs should explain why they think your long-term medication is the right choice for you. Regular everyday movements around the house are better than taking to your bed. If possible, you could include some gentle stretching routines – the BackCare website is one place where you can find such 9

advice. As mentioned above, if you suspect that sciatica is the cause, don’t do any vigorous exercise before taking proper advice.

Mindset It has been shown that psychological therapies, particularly cognitive behavioural therapy (CBT) can produce moderate reductions in pain. The effect can be even better when combined with exercise. (Cashin 2026) Unfortunately, access to therapies such as CBT can have long waiting lists in some areas, if available at all. There is also recent guidance from NICE (NG59, covering low back pain), which the NHS generally follows, recommending the withdrawal of purely psychological therapies owing to insufficient evidence for effective outcomes. This does not mean that they have completely abandoned how “psychological” treatments can help manage pain but instead are looking to combine them with physical therapies. It has been demonstrated that people who have particular, positive attitudes (higher confidence and lower anxiety) are likely to make a better recovery from sports injuries than those who don’t. A possible explanation is that this leads to a reduction in feelings of stress, so improving immune function and resulting in more efficient tissue repair. (Al Tarsha 2026) This explanation has not been proved but the association between attitude and recovery is real. Depression and negative emotional states have a huge impact on wellbeing. People can become trapped in their current situation by what they believe to be possible. If you have been told, or are telling yourself, there is no hope, you are unlikely to ever challenge these mental boundaries. It’s very important to get help but more important to reinforce this by helping yourself. There are more suggestions in the Treatments section below on how to manage pain using a “psychological” approach.

What about lifestyle? At the time of writing, there are regularly stories in the press giving advice or warnings about how lifestyle choices can bring harm or benefit to your health. Stories take a scientific study and present it in such a way that if you “do/eat/drink” this or that you are 𝑥% more, or less, likely to get dementia, heart disease etc. It’s easy to be left thinking that the identified link (correlation) is the cause of / cure for the condition. When it comes to health, cause is often hard to identify and harder to prove. Who wouldn’t want a simple guide to follow, guaranteeing a long, healthy and pain-free life. This publication on back pain is currently unavailable! What is widely accepted is that there are certain lifestyle habits that can improve physical fitness and perhaps also improve feelings of wellbeing. BackCare booklets, available to read online, (via our website or directly from www.ISSUU.com/backcare ) provide general advice on managing or preventing back pain through daily habits and practices. A lot of our advice in the section below on Prevention also works well for dealing with pain. As you might expect, making changes to your lifestyle can be quite difficult and often needs determination. Try changing things gradually, getting used to new habits so that they become part of your routine. It should then be easier to tackle more changes – people who try to “fix” everything at once can become overwhelmed and give up.

What can happen? It can be very frustrating that modern medicine cannot always explain the exact cause of all episodes of back pain. However, it’s reassuring to know that the medical profession is generally very good at determining whether you have a serious problem. If this is the case, then a very small number of people require specialist treatment and even surgery. However, in most cases, people are not seriously ill and so many are left to deal with long-term pain. 11

Anecdotal evidence from people sharing their stories show that it is all too easy for individuals to fall into a downward spiral. Family and friends may not understand what it is like to have persistent pain; sympathy can be short-lived. Sometimes this leads to feelings of isolation and frustration which can reinforce each other. This coupled with possible lack of sleep, poor concentration and loss of energy, can result in low self-confidence, difficulty in completing everyday tasks, hopelessness and even depression. The final humiliation of being unable to work is common, leading to more worry and stress. Chronic back pain affects your body and your mind; it has a physical and a psychological aspect. This does not mean you are ‘making it up’ or ‘going mad’. Your pain is real and the modern attitude in the NHS accepts this and they are now gearing up to tackle this epidemic. That said, make sure you take steps to help yourself – people who do this usually have a better outcome.

Treatments In the above section, What is pain?, we listed some of the possible causes (and interactions) of why people experience chronic, primary (non-specific) pain – the majority of people who have LBP according to the quoted research. As an individual looking for help, finding an effective treatment might take time and perseverance because your particular situation may respond to some better than others. Some treatments are wellestablished and have been thoroughly researched while others are more experimental and less mainstream. When deciding what treatment to try, you might want to ask yourself the following questions: 1. Has the possibility of a serious underlying condition been ruled out? 2. Is there any scientific evidence that shows the treatment is effective and safe? Where available, BackCare uses scientific studies to support advice. 12

3. Who performs the treatment? Are they registered with a regulatory body? If not, are they adequately qualified to perform the treatment? 4. What are the possible benefits, risks and the costs of the treatment? When making a decision you will have to weigh these three. 5. Is the treatment on offer appropriate for my condition and my circumstances? 6. Can you get information and advice about the treatment on offer from multiple sources? 7. Have you spoken with anyone who has tried the treatment on offer? This may give you a better insight into what to expect. Below are only some examples of treatments used in managing back pain: – (more information is available on the BackCare website) Self-management This category is not really a treatment as it can cover just about everything that makes you feel better about your situation. It is, nevertheless, not to be dismissed lightly. As we’ve already said, the power of being positive and taking action can be effective. You should be aiming to eat well (see the section on Weight and Diet in the Prevention section below), sleep well, keep active and try to manage stress. In order to achieve these aims, you will have to choose options that are possible for your circumstances but remember, be strong and don’t put mental barriers in place that are just excuses. Again, try different things and don’t necessarily expect an overnight cure; we have some suggestions! There are courses available, either in person or more commonly online that help you to address long-term health conditions and / or pain. They offer specific advice on how to cope with all the typical aspects of dealing with such a situation. The BackCare website has links to 13

organisations / charities that offer such help but don’t be afraid to start up your search engine to help you find such courses yourself. Another popular solution is to join a pain support group. These groups are often made up of communities of people who have experienced problems with long term pain or disability. The setting might be face to face in a physical location or, often, using online forums, sometimes run by pain clinics but also by charities whose whole purpose is to help manage pain. This format adds another lever you can pull in the journey to managing your pain – social interaction. The combination of hearing positive experiences and social interaction has been shown to magnify healing – “psychosocial” in the jargon. Pain Clinics and Pain Management Programmes Pain Clinics and Pain Management Programmes are NHS services that have traditionally been accessed through a GP referral for people who are suffering with chronic pain. The NHS is organised differently in the four home nations of the UK so, depending on where you live, what is available and how you access these services can vary. NHS services often change, whether that is largely just in name, the locations where they are delivered or even when they are integrated into different programmes. You can always start with a GP consultation or do your own research to find out what is available in your area. There is more information on the BackCare website (Treatments page) about researching what the NHS provides where you live. Pain Clinics are often based in hospitals, but not all hospitals have one. The treatments do vary between clinics, some might prescribe drugs / give pain control injections while others have a multidisciplinary approach where a team, which could be made up of doctors, physiotherapists, psychologists and others, will treat you. Pain Management Programmes are mostly based in psychology, delivered by a team of healthcare professionals and usually last two to four weeks. The aim is to help patients cope with disability and distress 14

caused by persistent pain by teaching physical, psychological and practical techniques for self-management. At the time of writing, the NHS in England is starting to shift pain care into integrated MSK pathways. What this means in real terms is yet to be seen but again shows the importance of keeping up with the services offered in your local area. Alexander Technique The Alexander Technique is based on the principle that we function as a whole and, to make improvements, we need to learn to prevent unnecessary and harmful habits such as tightening muscles and joints and putting too much effort and tension into our posture and movements. The programme requires a series of individual lessons to learn the Alexander Technique. The teacher uses gentle touch and guides the pupil through simple movements such as sitting, standing, and walking. To learn more, visit www.alexandertechnique.co.uk where there is also a link to find a qualified teacher in your area. Chiropractic Chiropractors are primary healthcare professionals, specialising in the diagnosis, treatment and overall management of conditions of the joints, ligaments, tendons and nerves of the body, particularly those of the spine. Chiropractors use various different manipulative techniques and other treatment types depending on the individual patient's needs. Chiropractors also provide advice and assistance in rehabilitation to help prevent problems from re-occurring. Chiropractic is regulated by law, the government appointed regulator being the General Chiropractic Council (GCC) from whose website www.gcc-uk.org is a good starting point for learning more and finding a practitioner. 15

Osteopathy Osteopathy is a system of diagnosis and treatment for a wide range of medical conditions. It focuses on the integration of the musculoskeletal system with other body systems and the influence that impaired function of each has on the other. It also seeks to empower patients in assisting their recovery to good health. Osteopaths use touch, physical manipulation, stretching and massage to increase the mobility of joints, to relieve muscle tension, to enhance the blood and nerve supply to tissues, and to help your body’s own healing mechanisms. They also provide advice on posture, lifestyle and exercise to aid recovery, promote health and prevent symptoms recurring. To learn more about osteopathy, visit www.osteopathy.org.uk Physiotherapy Physiotherapy is a science-based healthcare profession that views movement as central to health and wellbeing. The range of conditions it can treat has a broad scope, covering the entire musculoskeletal system, post-surgical rehabilitation, neurological conditions, movement disorders, and functional recovery. Being a chartered physiotherapist means your clinician will have undertaken at least three years training and achieved the high standard required to become a member of the Chartered Society of Physiotherapy (CSP). This, along with the wide range of conditions treated, is, perhaps, why it is such a common referral path in the NHS. Unfortunately, waiting times for a referral can vary widely and sometimes people prefer to make their own arrangements to see a physiotherapist privately. Acupuncture Acupuncture treatment involves fine needles being inserted through the skin and briefly left in position. Sometimes manual or low voltage electrical stimulation is applied to assist the process. The number of needles varies but may be only two or three. The practitioner will 16

assess each patient’s case and treatment will be tailored to the individual. A typical course of treatment lasts 5 to 8 sessions. Acupuncture stimulates the nerves in skin and muscle and can produce a variety of effects. It is known to increase the body's release of natural painkillers - endorphin and serotonin - in the pain pathways of both the spinal cord and the brain. This modifies the way pain signals are received. There is evidence that it can reduce pain but the strength of that evidence varies with the condition being treated. The NHS does support its use (Guy's and St Thomas' NHSFT 2024) and a good starting point for learning more is the website of the British Medical Acupuncture Society: www.medical-acupuncture.co.uk Drugs for Pain Relief For new episodes of back pain, it is recommended to start by taking Paracetamol in the hope that allowing pain-free movement will help you to recover quickly. Another widely recommended drug for acute pain is ibuprofen which is part of a class known as NSAIDs (Nonsteroidal anti-inflammatory drugs). As the name suggests, this class of drugs can reduce inflammation and pain, so might appear the ideal choice. However, as with many drugs, there can be side effects. In some patients, indigestion, feeling sick and diarrhoea are quite common. They are not recommended for people with asthma, high blood pressure, liver and stomach problems, kidney and heart conditions. If you are in doubt, ask your pharmacist. Once we move into the area of chronic pain, the whole situation is much more complicated. Some drugs will almost certainly have some side effects; others may have addictive qualities that make it difficult to stop taking them and there is always the danger that any benefit you get in pain relief will become less effective over time. It is important, if you feel like you need stronger painkillers, to have a discussion with your GP. Make sure you ask about side effects, the risk 17

of addiction and why your GP believes this is the best treatment for you. Meditation There are different ways to meditate but they all aim to lower your stress levels. Meditation can help many people to feel calmer when dealing with everyday events that could otherwise cause an emotional response. One of the advantages is that you don’t need any expensive equipment – just time and a comfortable place. When combined with “mindfulness” – a way to help focus on the present moment – it can be even more effective. If you have trouble getting to sleep, try to include it as part of a wind-down routine. The NHS has information on meditation and mindfulness in its “every mind matters” section (NHS 2026) EMDR For chronic pain that results from the nervous system continuing to process pain signals unnecessarily or where pain is closely linked to trauma, EMDR is a new approach. Eye Movement Desensitisation and Reprocessing (EMDR) is a trauma-focused psychotherapy, that uses bilateral stimulation (most commonly, guided side-to-side eye movements) to help the brain reprocess distressing memories and their associated feelings, sensations, and beliefs. In simple terms, EMDR helps “unstick” traumatic memories, so they no longer trigger the same emotional and physical responses, and this could include some causes of back pain. When back pain has no clear physiological injury and remains undiagnosed, it could be linked to an onset of anxiety or unresolved traumatic experiences, the pain can be maintained by central nervous system sensitisation and conditioned responses that keep the body in a state of guarded tension. That tension can also increase the back pain as the body and the negative cycle only serves to increase pain over many years. It is here that EMDR can be directed at the traumatic trigger memories and the pain-related memories and fears, specifically targeting not only the core memories but also the secondary memory 18

components such as muscle tension and pain anticipation, that can all perpetuate chronic pain.

Prevention It’s our view that the way to look after your back to prevent injury and pain largely overlaps with advice for living a healthy lifestyle. Eat well, sleep well, exercise – do something to make yourself feel positive every day! It perhaps sounds a little too easy to say this when you are dealing with the problems and stresses of modern life. However, if you start to suffer with back pain, it’s likely you’ll still have those same worries, except you now have another problem to deal with.

Exercise (being active!) The most helpful thing you can do to prevent and manage back pain is to keep your back (and the rest of your body) fit and healthy. Eat well, sleep well and, perhaps most importantly, lead an active lifestyle is our view in a nutshell. Clearly, what we call “active” will depend on the individual. The take-home message is that regardless of your starting point, most of us can do more. For example, if you have a sedentary lifestyle, start slowly by making sure you get out of your chair regularly, use the stairs instead of the lift / escalator, go for a daily walk (use the fitness tracker on your phone to count steps and track progress), don’t use the car if you can walk or cycle. All these little changes can make a big difference to your overall physical activity level. Combine this with stretching and strengthening exercises – BackCare have a booklet called “Active Back Care” (available via our website or directly from ISSUU.com by searching the title as shown). There is an adage: “Don’t play sport to get fit, get fit to play sport” – we say, get fit for everyday life! Try to find a programme that has been designed for your ability level which can guide you safely through to better fitness, eg Couch to 5K from the NHS. 19

If you feel up to more demanding exercise, try to find something you will enjoy – most importantly, give it a chance to grow on you! Again, be realistic about your starting point but aim at increasing the intensity over time. Some exercises such as swimming, Pilates, walking and hydrotherapy are very popular among people with back pain. As an example, the WalkBack Trial, conducted by Macquarie University (Australia) in 2024, demonstrated that a structured walking programme helped adults with a history of LBP go twice as long without problems as a control group. (Hancock MJ 2024) Lace up your trainers! • • •

To get real benefits, exercise regularly Try to increase your level of activity gradually Try to stay motivated, activity can become addictive given a chance

Posture / Movement Your spine is an incredible structure that combines strength and flexibility. Looking sideways on you can see from Figure 1: The Spine that the spine has an elongated S-shape; with variations seen between individuals. Whatever the exact shape of your spine, it is designed for movement. This is why we often say that the best posture, is the next posture. Any posture will start to become uncomfortable after some time and regularly changing your posture is recommended. For many years, the advice has been to “maintain a good posture” in order to avoid back problems. In the modern world, some people will rightly ask, “but where is the evidence?”. Studies conducted in 2020 (Swain 2020), 2024 (Alshehri 2024) and 2025 (Sugavanam T 2025) attempted to examine whether “bad” posture causes low back pain. All three looked at other studies to see if this link could be proved. In all cases, it was not possible to prove a “causal” link but the 2025 study (looking at 22 other studies with almost 8,000 participants) found that there was a strong “association” between poor posture and low back pain along with a very strong “association” between long periods in one 20

position and low back pain. The other studies also pointed to lack of movement as having the strongest links to low back pain. However, it is much more difficult to get definite proof of cause when dealing with non-specific, back pain compared to a study that reports on a drug trial. The three studies were all cross-sectional (collecting results from people at the same time), not even following people over a time period (longitudinal study). The randomised controlled trial (RCT) is the gold standard for proving cause. Here participants are assigned at random to different treatments / therapies such that nobody knows which group they are in. This makes it easier to examine the outcomes of following / or not following a particular treatment and so prove cause. This works well in drugs trials – nobody knows whether the tablet is real or not – but not so well when asking people to sit in a certain way for a certain time. Another thing to bear in mind is that it has been shown, using MRI scans, that the pressure put on the discs in your lumbar spine (the inwards curve in the lower back) during upright, unsupported sitting is increased by about 40% compared to standing. These scans also show that static sitting increases muscle fatigue and ligament strain, yet reclined sitting (100°–130°) with lumbar support reduces disc pressure. (Roman-Liu 2023) We might conclude that if we are in one position for too long, it’s better to have proper lumbar support which maintains the natural curve of the lower spine.

Relaxing Choosing sofas and armchairs for the living room is not something most of us do very often, so it pays to make good choices – particularly if you spend a lot of time sitting. When going round a huge furniture showroom trying them out, it can be easy to rule out what feels uncomfortable, but what are the features should you be looking for. Unsurprisingly, we are coming at the choice from the angle of back health not colour and material! Our suggestions involve trying to keep the spine in its natural “S” shape to reduce disc pressure (see the section above on what MRI scans 21

have to say) and what goes for sofas, goes for armchairs. Things to think about are the height of the seat off the ground, the depth (from backrest to the front edge of the sofa), the size and slope of the backrest and the firmness of sofa itself. With regard to height, it’s not ideal to have your feet dangling in the air but at the same time if the seat height is too low, your hips will sink downwards with knees left higher. This can also happen where the sofa itself is very soft – some people put a board under the sofa cushion (if removable) to reduce the “squashiness”. Ideally, your hips should be slightly higher than your knees, feet firmly planted on the floor. Some adjustments might be necessary if your family are of very different heights. If the sofa is too deep (front to back), your lumbar spine can be left unsupported. This can often be fixed by using a small cushion or lumbar roll against the backrest to support the lower part of your spine. In fact, this kind of support for your lower spine is always a good idea. Make sure that the backs of your knees are not “trapped” against the front edge of the sofa. The backrest should not be too low and, if possible, allow for a slight “leaning back” but not too much! We are trying to maintain that neutral position of your spine. If your sofa or armchair has a “rest” that can be raised to support your feet /calves, much of the above still applies. Don’t let your hips sink too low and maintain a slight backward lean with good lumbar support. Don’t stay in the same position for too long. Other things that we would avoid: • •

Lying down on your side with your head on the armrest Sitting with one leg tucked underneath you

Overall, if you struggle to get out of your sofa/armchair, it’s probably too low or too soft. Speaking of “getting out”, don’t spend too long sitting in the same position – movement is our friend! 22

Sleeping Sleep isn’t just “rest” – it’s a biological maintenance cycle. Although its purpose hasn’t been fully explained, scientists have good evidence for many of the beneficial effects. (Brinkman 2026) Sleep is made up of four different stages that repeat in cycles. So, let’s take a look at some of the things that happen during this very complicated process and how it affects your health: (Nunez 2024) •

• •

• • • • •

Energy saving at night: when humans evolved, gathering and hunting for food was a daylight activity, the body uses less calories when sleeping Cell repair: muscle and tissue repair and growth are examples Brain function: toxic byproducts build up in the brain during the day. Sleep helps to improve learning, concentration, problem solving amongst other things Emotional well-being: good sleep can help with stress responses Weight maintenance: control of hunger hormones Insulin function: prevention against type 2 diabetes Immune system: keeping the balance, producing immune cells regulating inflammation Heart health: lack of sleep has been associated with increased risk of heart disease

When sleep is disrupted, the proper maintenance cycle might not work as well and the adverse effects on your wellbeing can accumulate over time. Sleep deficiency has been linked to chronic health problems that can affect the heart, kidneys, blood, brain and mental health. It is perhaps no surprise that it is one of the four pillars that support our pain management strategy. If you’re not sleeping well, then it’s really important to try to fix the situation. There is a lot of advice available on tips and tricks to fall asleep more easily and improve the quality of your sleep. 23

For example, the NHS has a page on this subject in its “every mind matters” section (NHS 2026). There are also a lot of resources available on the excellent website: https://www.thesleepcharity.org.uk A major factor in improving your sleep “environment” is the bed itself, the mattress and pillows in particular. Mattresses don’t last for ever and if you suspect that yours could be causing problems, it might be worth looking into getting a new one. Choosing a mattress, usually an expensive purchase, is not something you want to get wrong. As a starting point, you could try https://bedadvice.co.uk/ for some ideas on this. Don’t forget your pillow either – particularly if you get a sore neck. For something that appears so simple, there’s a lot that can go wrong with pillows. We recommend choosing a pillow(s) so that your neck is well supported but not “tilted” at an unnatural angle because your head is too high or low. Having the right material can also make a difference – laying your head on something that feels hot is unlikely to help with a good night’s sleep. If you are thinking of spending a lot of money on an orthopaedic pillow, for example, do some research rather than buying the first thing with impressive marketing claims. If you look at a site that compares different brands, make sure they are recognised for doing independent reviews. Some companies offer a trial period on pillows and mattresses – make sure to check the terms and conditions carefully. Where possible, find out what other people have to say about the products / customer service. Clearly, being in pain can make sleeping much more difficult but there is a lot of advice out there and it’s important to keep trying different things. Each person will have their own experiences, so, as we keep saying, self-help is vital in this journey.

Handheld Devices It seems common for people to spend a lot of time looking at their phones. This is not just regular checking; this is also intense 24

concentration for long periods. These amazing devices can turn us into statues – downward looking statues. If you recognise yourself, be kind to your neck and have a regular break – you could even try some gentle “neck-rolling” or “shoulder shrugs” (see the section on Chairs / Workstations below).

Weight and Diet Being overweight puts extra pressure on all of your body’s structures particularly your spine. Over time this may increase your risk of developing back pain. You might also find it more difficult to get involved in physical activity; being active is strongly associated with improving back pain and preventing it in the first place. There are other good reasons for controlling what you eat. As already mentioned, chronic inflammation can be linked to persistent back pain. The foods we eat can have a significant effect on inflammation in our bodies, both positive and negative. You might be familiar with the basic advice of eating a “balanced” diet – a spread of protein, carbohydrate and fibre avoiding too much fat, salt and sugar but there is very much more to our complicated relationship with food. For Backcare Awareness Week in 2025, we commissioned a booklet, Eating to Ease Back Pain, written by Yinka Thomas, a lecturer at Middlesex University. This excellent booklet explores how food can be a powerful “treatment” in dealing with pain. Read online by visiting our Back Care Awareness Programme page.

Smoking Smoking not only increases your risk of developing heart disease and cancer but can also add to your risk of developing back pain. Although the actual mechanisms are complicated the evidence suggests that tobacco smoking is a major risk factor for degenerative spinal diseases, particularly in the lower back. Furthermore, smokers experience a greater need for surgery and post-operative complications. (Rajesh 2022) 25

At Work All employers have legal responsibility under the Health and Safety at Work Act 1974 and Management of Health and Safety at Work Regulations 1999 to ensure the health safety and welfare of their employees at work. Additionally, the Workplace (Health, Safety and Welfare) Regulations 1992 extend these duties. Most of this legislation is based on common sense but the full Acts and Regulations are complicated and wide-ranging in their reach. At the very least, your employer should have acted on some basic requirements. Depending on the number of employees (which largely affects documentation), examples could be: • • • • • • •

Identifying potential workplace risks by assessment Provide information and training to workers on safety Consulting and sharing information with workers Have a health and safety policy First aid provision Have a way to report accidents and near misses Appointing a competent person

If you feel that your workplace or the work you do could put you at risk of injury or illness, it is a good idea to speak informally to someone in your organisation. Every employer should appoint a “competent” person to ensure that the organisation meets its health and safety obligations. This should be a good starting point if you feel concerned. If you don’t feel satisfied that your employer has acted on your concerns, one possible course of action is to contact the Citizens Advice Bureau (CAB) for guidance on what to do next.

Workplace adjustments If you have a long-term injury or condition (this might include low back pain), it could be considered a disability under the Equality Act 2010. Medical evidence will probably be required. In this case, an employer must make reasonable adjustments to allow you to work without being 26

put at a disadvantage. The word reasonable depends on circumstances and to some extent the size and resources of the employer. However, some adjustment will be expected. Each situation will be different but some examples of adjustment could be: • • • • •

Flexible or reduced hours Phased return to work Adapted equipment in your workspace Layout changes Working from home

Even when your injury doesn’t meet the Equality Act definition of disability, your employer probably has obligations under other legislation or Acts to protect your health and safety. Adjustments could reasonably include the list immediately above. It’s probably a good idea to have a meeting with your line manager to try to agree what can be done to make your working situation comfortable. Often, employers are receptive to suggestions that will allow you to continue working. However, what is reasonable might not be clear-cut, in which case you might need specialist advice.

Lifting / Manual Handling Lifting heavy objects, especially when you have to do this repetitively, can increase your risk of developing back pain. There are basic guidelines that you can follow when doing jobs around the home / in the garden: • • • •

When carrying or lifting objects, keep the load close to your body Try to avoid lifting while twisting at the same time When lifting, lift from the knees and not the back. Get as close as possible to the load and make sure your stance is stable Ask for help when lifting and carrying heavy or awkwardly shaped items 27

•

Use lifting aids when available making sure you know how to use them properly

If you lift / move heavy or awkwardly shaped objects as part of your job, your employer has obligations under HSE regulations to provide you with training and, where appropriate, suitable equipment.

Chairs / Workstations So many of us spend time sitting at a desk looking at a screen for long periods, be that in an office or at home. Configuring your workstation to ensure a neutral position for the spine seems like a good investment. Traditionally chairs were designed with flat seats so you could sit with your knees and hips horizontally aligned. However, nowadays most chairs allow you have your hips slighter higher than your knees, so your upper legs are sloping down. This promotes a more natural S shape in your back. If you work from home, it can be tempting to use a traditional dining/kitchen chair that has no adjustment. Sometimes people say an adjustable chair takes up too much space or doesn’t fit in with the look of their room. These are understandable objections, but do you really want to risk the misery of a bad back? If you use armrests, make sure you can place your elbows / arms on the armrests with your shoulders relaxed. The armrests should not restrict you from placing your chair near your desk. There are a number of aids available that can help with adjusting your chair to the settings you prefer. A lumbar roll can help with keeping a natural curve in your lower back. A wedge on your seat can help with having your upper legs sloping down, which again promotes a natural S-shape in your spine. A footrest is useful if you find that your feet cannot reach the floor when you have adjusted your chair correctly. •

Modern desks are often height adjustable; some even convert to allow you to work standing up. If you have a traditional desk, you can use blocks or desk height adjusters to position it higher 28

• • • • •

• •

•

Ensure you have all items you need regularly (e.g. mouse, keyboard, telephone, reference documents) within easy reach Use a headset if you often make long phone calls Adjust your chair so it is comfortable for you (as explained above). You may also need to adjust the height of your desk If you work on a laptop, try to use a separate keyboard/mouse/monitor The top of your monitor should be at eye level avoiding a forward tilting of your head. Place the monitor at approximately an arm’s length to ensure the correct viewing distance If you use your computer regularly, place the monitor and keyboard in front of you so you don’t have to twist or turn to it If you use a phone at your workstation, try using a headset/ear buds or even use it on speaker / stand up if you are in your own workspace. Whatever you do, don’t cradle it between your shoulder and ear Go for a walk at lunch time – come back refreshed

Remember that movement is the friend of your spine – even standing up briefly is better than maintaining the same posture for too long. If you spend a lot of time working at a desk, even some simple exercises while seated can make a difference to your wellbeing. Try some “office gymnastics” such as: 1. Lateral neck rotations: turn your head left and right and hold for a count of three in each position. 2. Shoulder shrugs: gently raise and lower your shoulders. 3. Seated calf-raises: raise your heels and hold for a count of three. 4. Resisted arm curls: gently raise your lower arm against downward pressure from your top arm. 5. Wrist rolling: flex, stretch and roll your wrists. 6. Hand/finger exercise: place an elastic band around your fingers and stretch your fingers against the resistance of the elastic band. 29

Lateral Neck Rotations

Shoulder Shrugs

Seated Calf Raises

Resisted Arm Curls

Wrist Rolling

Hand/Finger Exercise

Figure 2: Exercises

Conclusion Non-specific lower-back and musculoskeletal pain sits at the intersection of biology, psychology, lifestyle, and circumstance. It rarely has a single cause, and it rarely has a single solution. Throughout this booklet, we’ve explored chronic pain, the medications and therapies commonly used, and the lifestyle approaches that can support recovery or improve day-to-day comfort. These tools matter — 30

but they are not universal answers, and they will not work in the same way for everyone. Living with persistent pain can be exhausting, frustrating, and at times isolating. It is important to recognise that progress is often gradual, non-linear, and deeply personal. What helps one person may be unhelpful or even counterproductive for another. That does not mean the pain is “in your head”, nor that you have failed to do something “right”. It simply reflects the complexity dealing with chronic pain and the individuality of each person’s experience. This booklet is not intended to replace professional medical advice, nor to suggest that the strategies described will resolve every case of non-specific pain. Instead, it offers a starting point — a framework for understanding, a menu of options to explore, and reassurance that there are multiple pathways to relief and better function. For some, small changes in movement, sleep, or stress may unlock meaningful improvement. For others, structured therapy, medication, or specialist support may be necessary. And for many, the most helpful approach will be a combination of strategies applied over time. If your pain persists, worsens, or affects your ability to live the life you value, seeking guidance from a qualified healthcare professional is essential. No one should navigate chronic pain alone. But with the right support, the right information, and a willingness to explore what works for your body, it is possible to move towards greater comfort, confidence, and control.

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Roman-Liu, D et al. 2023. “Differences in lumbar spine intradiscal pressure between standing and sitting postures: a comprehensive literature review.” PeerJ 11:e16176. Sugavanam T, et al. 2025. “Postural asymmetry in low back pain – a systematic review and meta-analysis of observational studies.” Disability and Rehabilitation. 47(7): 1659:1676. Swain, Christopher TV et al. 2020. “No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews.” Journal of Biomechanics Volume 102: 109312. The British Pain Society. 2026. Home Page. Accessed 08 2026. https://www.britishpainsociety.org/.