small benefit in the short-term for radicular low back pain, however, the benefit for non-radicular back pain and the optimal dose and length of treatment is unclear. specialist groups advise against general long-term use of opioids for chronic low back pain. as of 2016, the cdc has released a guideline for prescribed opioid use in the management of chronic pain. it states that opioid use is not the preferred treatment when managing chronic pain due to the excessive risks involved. if prescribed, a person and their clinician should have a realistic plan to discontinue its use in the event that the risks outweigh the benefit. if the pain is still not managed adequately, short-term use of opioids such as morphine may be suggested. these medications carry a risk of addiction, may have negative interactions with other drugs, and have a greater risk of side effects, including dizziness, nausea, and constipation. opioid treatment for chronic low back pain increases the risk for lifetime illicit drug use and the effect of long-term use of opioids for lower back pain is unknown. for older people with chronic pain, opioids may be used in those for whom nsaids present too great a risk, including those with diabetes, stomach or heart problems. they may also be useful for a select group of people with neuropathic pain. antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects. although the antiseizure drugs gabapentin, pregabalin, and topiramate are sometimes used for chronic low back pain evidence does not support a benefit. systemic oral steroids have not been shown to be useful in low back pain. facet joint injections and steroid injections into the discs have not been found to be effective in those with persistent, non-radiating pain; however, they may be considered for those with persistent sciatic pain. epidural corticosteroid injections provide a slight and questionable short-term improvement in those with sciatica but are of no long-term benefit. there are also concerns of potential side effects. surgery surgery may be useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control. it may also be useful in those with spinal stenosis. in the absence of these issues, there is no clear evidence of a benefit from surgery. discectomy (the partial removal of a disc that is causing leg pain) can provide pain relief sooner than nonsurgical treatments. discectomy has better outcomes at one year but not at four to ten years. the less invasive microdiscectomy has not been shown to result in a different outcome than regular discectomy. for most other conditions, there is not enough evidence to provide recommendations for surgical options. the long-term effect surgery has on degenerative disc disease is not clear. less invasive surgical options have improved recovery times, but evidence regarding effectiveness is insufficient. for those with pain localized to the lower back due to disc degeneration, fair evidence supports spinal fusion as equal to intensive physical therapy and slightly better than low-intensity nonsurgical measures. fusion may be considered for those with low back pain from acquired displaced vertebra that does not improve with conservative treatment, although only a few of those who have spinal fusion experience good results, and there may be no clinically important difference between disk replacement and fusion surgery. there are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others. adding spinal implant devices during fusion increases the risk but provides no added improvement in pain or function. alternative medicine it is unclear if alternative treatments are useful for non-chronic back pain. chiropractic care or spinal manipulation therapy (smt) appear similarly effective to other recommended treatments. national guidelines differ, with some not recommending smt, some describing manipulation as optional, and others recommending a short course for those who do not improve with other treatments. a 2017 review recommended smt based on low-quality evidence. there is insufficient evidence to recommend manipulation under anaesthesia, or medically assisted manipulation. smt does not provide significant benefits compared to motor control exercises. acupuncture is no better than placebo, usual care, or sham acupuncture for nonspecific acute pain or sub-chronic pain and there is no evidence that it improves function when compared to a sham or placebo treatment. for those with chronic pain, it improves pain a little more than no treatment and about the same as medications, but it does not help with disability. this pain benefit is only present right after treatment and not at follow-up. acupuncture may be an option for those with chronic pain that does not respond to other treatments like conservative care and medications, however this depends on on patient preference, the cost, and on how accessible acupuncture is for the person. massage therapy does not appear to provide much benefit for acute low back pain. massage therapy has been found to be more effective for acute low back pain than no treatment; the benefits were found to be limited to the short term and there was no effect for improving function. for chronic low back pain, massage therapy was no better than no treatment for both pain and function, though only in the short-term. the overall quality of the evidence was low and the authors conclude that massage therapy is generally not an effective treatment for low back pain. massage therapy is recommended for selected people with subacute and chronic low back pain, but it should be paired with another form of treatment like aerobic or strength exercises. for acute or chronic radicular pain syndromes massage therapy is recommended only if low back pain is considered a symptom. mechanical massage tools are not recommended for the treatment of any form of low back pain. prolotherapy – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body's healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy. herbal medicines, as a whole, are poorly supported by evidence. the herbal treatments devil's claw and white willow may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant. capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function. behavioral therapy may be useful for chronic pain. there are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors; cognitive behavioral therapy, which helps people identify and correct negative thinking and behavior; and respondent conditioning, which can modify an individual's physiological response to pain. the benefit however is small. medical providers may develop an integrated program of behavioral therapies. the evidence is inconclusive as to whether mindfulness-based stress reduction reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain. tentative evidence supports neuroreflexotherapy (nrt), in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain. multidisciplinary biopsychosocial rehabilitation (mbr), targeting physical and psychological aspects, may improve back pain but evidence is limited. there is a lack of good quality evidence to support the use of radiofrequency denervation for pain relief. kt tape has been found to be no different for management of chronic non-specific low back pain than other established pain management strategies. education there is strong evidence that education may improve low back pain, with a 2.5 hour educational session more effective than usual care for helping people return to work in the short- and long-term. this was more effective for people with acute rather than chronic back pain. the benefit of training for preventing back pain in people who work manually with materials or is not clear, however moderate quality evidence does not show a role in preventing back pain. prognosis overall, the outcome for acute low back pain is positive. pain and disability usually improve a great deal in the first six weeks, with complete recovery reported by 40 to 90%. in those who still have symptoms after six weeks, improvement is generally slower with only small gains up to one year. at one year, pain and disability levels are low to minimal in most people. distress, previous low back pain, and job satisfaction are predictors of long-term outcome after an episode of acute pain. certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain. following a first episode of back pain, recurrences occur in more than half of people. for persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. at one year, those with chronic low back pain usually continue to have moderate pain and disability. people at higher risk of long-term disability include those with poor coping skills or with fear of activity (2.5 times more likely to have poor outcomes at one year), those with a poor ability to cope with pain, functional impairments, poor general health, or a significant psychiatric or psychological component to the pain (waddell's signs). prognosis may be influenced by expectations, with those having positive expectations of recovery related to higher likelihood of returning to work and overall outcomes. epidemiology low back pain that lasts at least one day and limits activity is a common complaint. globally, about 40% of people have lbp at some point in their lives, with estimates as high as 80% of people in the developed world. approximately 9 to 12% of people (632 million) have lbp at any given point in time, and nearly one quarter (23.2%) report having it at some point over any one-month period. difficulty most often begins between 20 and 40 years of age. low back pain is more common among people aged 40–80 years, with the overall number of individuals affected expected to increase as the population ages. it is not clear whether men or women have higher rates of low back pain. a 2012 review reported a rate of 9.6% among males and 8.7% among females. another 2012 review found a higher rate in females than males, which the reviewers felt was possibly due to greater rates of pains due to osteoporosis, menstruation, and pregnancy among women, or possibly because women were more willing to report pain than men. an estimated 70% of women experience back pain during pregnancy with the rate being higher the further along in pregnancy. current smokers – and especially those who are adolescents – are more likely to have low back pain than former smokers, and former smokers are more likely to have low back pain than those who have never smoked. history harvey williams cushing, 1920s low back pain has been with humans since at least the bronze age. the oldest known surgical treatise – the edwin smith papyrus, dating to about 1500 bce – describes a diagnostic test and treatment for a vertebral sprain. hippocrates (c. 460 bce – c. 370 bce) was the first to use a term for sciatic pain and low back pain; galen (active mid to late second century ce) described the concept in some detail. physicians through the end of the first millennium recommended watchful waiting. through the medieval period, folk medicine practitioners provided treatments for back pain based on the belief that it was caused by spirits. at the start of the 20th century, physicians thought low back pain was caused by inflammation of or damage to the nerves, with neuralgia and neuritis frequently mentioned by them in the medical literature of the time. the popularity of such proposed causes decreased during the 20th century. in the early 20th century, american neurosurgeon harvey williams cushing increased the acceptance of surgical treatments for low back pain. in the 1920s and 1930s, new theories of the cause arose, with physicians proposing a combination of nervous system and psychological disorders such as nerve weakness (neurasthenia) and female hysteria. muscular rheumatism (now called fibromyalgia) was also cited with increasing frequency. emerging technologies such as x-rays