Lower back pain is the leading cause of disability globally but too often patients are let down by the treatment they are offered, say experts.
They have written a series of papers in The Lancet asking the worldwide medical profession to stop offering ineffective and potentially harmful treatments.
Strong drugs, injections and surgery are generally overkill, they say, with limited evidence that they help.
Most back pain is best managed by keeping active, they advise.
Recommendations that doctors follow in the UK are clear about what investigations and treatment patients should expect.
Some patients will require a scan to rule out underlying causes, but in most cases they are deemed unnecessary because they are likely to be inconclusive.
Signs that something more significant might be wrong include:
- difficulty passing urine
- feeling the needing to pass urine, when there is none there
- impaired sexual function such as loss of sensation during intercourse
- numbness or tingling in the genitals or buttocks
- loss of bladder or bowel control
- loss of power in legs
Most adults will experience back pain at some point.
Episodes are usually short-lasting with no consequence, but recurrence is common – about one in three people will have a recurrence within a year of recovering from a previous bout, according to the researchers.
UK guidelines recommend a mix of physical exercise, advice and support to help patients cope with symptoms and enjoy a better quality of life.
Health staff should not treat back pain or sciatica with equipment such as belts, corsets, foot supports or shoes with special soles.
They should not offer acupuncture, traction (stretching the back using weights or machines), or electrotherapy (passing electric current or ultrasound waves through the body), says the National Institute for Health and Care Excellence.
A doctor may offer an opioid pain medicine, such as codeine, if anti-inflammatory drugs, such as aspirin, have not helped or the doctor thinks they are not right for the patient.
But opioid pain medicine can cause dependence.
Ten things you should know about your back
1) Your back is stronger than you may think – the spine is strong and not easily damaged, so in most instances the pain will be down to a simple sprain or strain
2) You rarely need a scan
3) Avoid bed rest and get moving (but avoid aggravating activities)
4) Do not fear bending or lifting – do it in a way that is comfortable, using the hips and knees
5) Remember that exercise and activity can reduce and prevent back pain
6) Painkillers will not speed up your recovery
7) Surgery is rarely needed
8) Get good quality sleep if you can, because it will help you feel better overall
9) You can have back pain without any damage or injury
10) If it doesn't clear up, seek help but don't worry – book an appointment to see your doctor or physiotherapist if the pain persists
Prof Martin Underwood, from Warwick University, who is one of the 31 authors of The Lancet papers, said: "Our current treatment approaches are failing to reduce the burden of back pain disability.
"We need to change the way we approach back pain treatment in the UK and help low- and middle-income countries to avoid developing high-cost services of limited effectiveness.
"Quite a lot of people get exposed to high-tech medical and invasive procedures. There's very little evidence base to support their use."
Prof Helen Stokes-Lampard, who chairs the Royal College of GPs, said: "One size does not fit all."
"We know that being active and working is good for our patients' health, so GPs and our teams will readily advocate lifestyle changes to patients that can help ease their pain and keep them in work, but for some patients, particularly in more serious cases, there is a limit to how realistic a significant amount of exercise is.
"For these patients whilst not a cure, drug-therapy can provide a great deal of relief and should not be dismissed entirely – the most effective approach, as with any medication, is that it should be prescribed at the lowest possible dose for the shortest possible time."
She added: "It is also the case that access to psychological treatments, such as talking therapies, which we know can be beneficial for patients suffering from lower back pain, is patchy across the country."