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Lower Back Pain for Years: What the Guidelines Say to Try

Low back pain that has lasted years is the case the research covers least. Guidelines define chronic pain as lasting 3 months or longer, and the cohort studies that follow people over time enter them at a set point, in the 2024 review within a year of onset. This page sets out what the guidelines recommend for long-running pain, what they advise against, how large the average effect of the best-studied option is, and a way to judge whether what you try is doing anything.

I had low back pain for about ten years and have no medical or physical-therapy credentials. Every figure below comes from a source listed at the end of the page.

Check what needs a clinician first

Go to emergency care now for new numbness, tingling or change in feeling in the saddle area (around the groin, inner thighs, genitals or anus, or when you wipe), new trouble getting or keeping an erection, not being able to orgasm, or a change in feeling during sex, new bladder or bowel changes (trouble starting or stopping pee, a weak stream, not feeling when you need to go, or leaking pee or poo), new pain, tingling, numbness or weakness in both legs, leg or foot weakness that is getting worse (tripping, a foot that slaps down), or back pain that started after a recent serious accident, like a car crash or a bad fall. See a clinician today (urgent care if you cannot get an appointment today) for other new weakness or numbness in one leg or foot, fever or chills with the back pain, new pain after a recent smaller fall or knock, unexplained weight loss or a history of cancer, pain that is rapidly getting worse, or pain that is constant at rest and worse at night, not tied to movement. The red-flag checklist has the full list.

Pain you have had for years can still change character. A new pattern that does not match your usual back pain is worth a visit, and so is pain that nobody has assessed since it began to change. The appointment questions page lists what to ask.

What the studies say about pain that lasts

The 2024 CMAJ meta-analysis by Wallwork and colleagues pooled cohorts of people whose pain had lasted 12 to less than 52 weeks when they entered the study. In that group, average pain on a 100-point scale was 56 at the start, 48 at 6 weeks, 43 at 26 weeks and 40 at 52 weeks. The authors rated that evidence very low certainty, and the range around each average was wide. None of those cohorts started from pain that was already years old, so there is no average to quote for your case.

Pain that has lasted months changed slowly, and average pain a year later was still around 40 out of 100. The why your back still hurts page covers how long-running pain works, and what your back MRI means covers what scan findings do and do not explain.

What the three guidelines recommend for chronic pain

• The American College of Physicians (2017) says to start with treatments that are not drugs: exercise, multidisciplinary rehabilitation, acupuncture and mindfulness-based stress reduction (moderate-quality evidence), and tai chi, yoga, motor control exercise, progressive relaxation, EMG biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy and spinal manipulation (low-quality evidence). After an inadequate response it names NSAIDs first, tramadol or duloxetine second, and opioids only after those have failed and only if the benefits outweigh the risks.
• WHO (December 2023), for chronic primary low back pain, recommends education that supports self-care, exercise programs, spinal manipulative therapy and massage, cognitive behavioural therapy, and NSAIDs, as care tailored to the person and often combined. It lists 14 interventions that should not be routinely offered because the harms likely outweigh the benefits, including lumbar braces, belts and supports, traction, and opioid painkillers.
• NICE NG59 (updated July 2026) says to give advice that helps people manage their own pain and keep up normal activities, to consider a group exercise program within the NHS for a specific episode or flare-up, and to consider manual therapy only as part of a package that includes exercise. It says not to offer belts or corsets, traction, acupuncture, TENS, ultrasound, opioids for chronic low back pain, or spinal injections for low back pain.

The guidelines disagree in places. ACP lists acupuncture and NICE says not to offer it. All three list exercise, and NICE also says to give advice and encourage normal activities. WHO and NICE both say not to use braces, traction or opioids for long-running low back pain: WHO says they should not be routinely offered for chronic primary low back pain, and NICE says do not offer them (opioids: for chronic low back pain). ACP considers opioids only after other options have failed, only if the benefits outweigh the risks, and after a discussion of known risks and realistic benefits.

What the largest exercise review found

The 2021 Cochrane review by Hayden and colleagues included 249 trials of exercise for chronic non-specific low back pain, meaning pain longer than 12 weeks. Compared with no treatment, usual care or placebo, exercise reduced pain by about 15 points on a 100-point scale at the first follow-up (moderate-certainty evidence), which the authors counted as clinically important. The gain in day-to-day function was about 7 points, below their threshold. Compared with other conservative treatments, exercise did a little better on pain (about 9 points, low-certainty evidence), but the authors did not count that as clinically important, and it did about the same as manual therapy. Among the 12 trials that measured harms systematically, the harms were mostly minor, such as muscle soreness.

The chronic low back pain exercises page compares the main types.

A way to judge what you try

This is my own method, not a tested protocol:

1. Pick one approach that has guideline support, and change one thing at a time.
2. Write down two measures before you start: your usual pain on a 1 to 10 scale, and something you can do, such as minutes of sitting, walking distance or reps of an exercise.
3. Keep the plan steady for several weeks before you judge it, and log both measures weekly.
4. Agree a review date with a clinician. If neither measure has moved by then, ask what to change.

A rising number on the second measure is information even when the first is flat. Expect flares along the way. The flare-up plan covers the bad days.

Ten years of it

I had low back pain for about ten years, from my early twenties into my thirties. A doctor prescribed anti-inflammatories. Chiropractors offered weekly adjustments. Physical therapy helped more than anything else, but the exercises came on a printed sheet and never got harder. Dry needling, YouTube stretch routines and the McGill Big 3 did not change much for me. What did was a slow back-extension progression on a 45-degree bench. I started with a few bodyweight reps and over about eight months worked up to loaded sets, doing a little and checking my back the next morning before doing more. My pain went down a lot. Read the story.

Everyone's back is different, so results vary and aren't guaranteed. A Cochrane review of 249 trials found that exercise programs for chronic low back pain reduced pain on average compared with no treatment, usual care or placebo, by about 15 points on a 100-point scale at the first follow-up (closest to 3 months), and improved day-to-day function by a smaller amount. This exact progression has not been tested in a trial. The app is not medical treatment; talk to your doctor before starting a new exercise program, and stop and get help if you have any of the warning signs listed in the app.

Low Back Pain Coach is an app that runs a bench progression with a next-morning pain log. It needs the bench, and the app page has what it does and costs.

Common questions

The app