Medication, Exercise and Physiotherapy

What is it?

For most types of pain, the first step is not a procedure but a plan: reviewing your medicines, regular exercise, physiotherapy and advice on daily habits. Doctors call this conservative treatment, meaning care without surgery or interventional procedures.

This step is the foundation of treatment for many conditions, including low back pain, neck pain, sciatica caused by a disc herniation, neuropathic pain and fibromyalgia.

When is it considered?

Without emergency signs or worsening weakness, treatment for most new episodes of pain starts here. Back and neck pain often eases within weeks; meanwhile the aim is to control the pain while keeping you moving.

This step matters for long-standing (chronic) pain too: medicines that no longer help or interact with each other are simplified, and muscles weakened by inactivity are rebuilt with a gradual programme.

How are medicines reviewed?

The choice of medicine depends on the type of pain: pain from muscles and joints responds to different medicines than nerve pain. The aim is not to remove pain completely, but to reduce it enough for you to keep up with exercise and daily life. The groups below are for general information only; your doctor decides on the medicine, dose and duration after examining you.

Pain relievers and anti-inflammatory medicines

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for back and joint pain. Because they can affect the stomach, kidneys, heart and blood vessels, they are taken at the lowest effective dose for as short a time as possible. Whether you also need stomach protection depends on your age and other health conditions.

Nerve-pain medicines

For nerve pain, often described as burning, tingling, stabbing or like an electric shock, some medicines from the antidepressant and anti-epileptic groups are used. Here they are given not to treat depression or epilepsy, but to change the way the nervous system processes pain signals. They are usually started at a low dose and increased gradually while side effects are monitored. For leg pain caused by a disc herniation (sciatica), a clear benefit has not been shown and some guidelines advise against them; whether to use them is decided together at your consultation.

Muscle relaxants, skin treatments and opioids

Muscle relaxants may be used briefly in selected cases but can cause drowsiness. For pain in one small area, creams or patches may be an option. Guidelines advise against opioids for long-standing low back pain; for a severe new episode they may be used briefly in selected cases, with close monitoring. Cancer pain is managed differently.

Each medicine is reviewed at follow-up visits; those that are not helping are reduced and stopped in a planned way.

Exercise and physiotherapy

Guidelines recommend regular, structured exercise as a core part of treatment for long-standing back and neck pain. The programme is tailored to you and may include strengthening and stretching, aerobic exercise such as walking or swimming, and mind-body approaches such as yoga or Pilates.

A physiotherapist builds the programme around your pain and fitness, checks your technique and increases the challenge step by step. Manual therapy may be added where appropriate, but alongside exercise rather than instead of it. Heat or cold can give short-term relief. Device-based treatments such as electrical nerve stimulation (TENS) or therapeutic ultrasound are not recommended by guidelines for low back pain.

Posture, activity and sleep

• Stay active: prolonged bed rest can slow recovery. Carry on with daily activities as far as the pain allows.
• Avoid staying in one position for long: if you work at a desk, get up and walk for a few minutes every 30-60 minutes.
• Pace your activities: rather than doing too much on good days and very little on bad ones, spread tasks through the day.
• Lift with care: keep the load close to your body, bend your knees and avoid twisting while you lift.
• Look after your sleep: keep regular hours and cut down on caffeine and screens in the evening; pain and sleep affect each other.

With long-standing pain, stress, anxiety and low mood can make pain feel stronger; psychological support may then become part of the plan.

When might you notice results?

With a new episode of back or neck pain, relief often comes within days to a few weeks. The benefit of exercise builds more slowly, over several weeks, and because nerve-pain medicines are increased gradually, it can take a few weeks to tell whether one is working.

Results vary from person to person. Mild soreness is common when you start exercising; if pain is sharp, spreads or worsens each time, the programme is adjusted.

When is the next step considered?

Image-guided interventional treatments are considered when:

• pain has not eased enough after several weeks of appropriate medication and exercise
• pain continues to clearly limit sleep, work or daily life
• pain makes it impossible to keep up with the exercise programme
• medicines cannot be used because of side effects

For severe pain travelling down the leg, an epidural steroid injection may be an option; for pain from the small joints of the spine, a facet joint injection and radiofrequency treatment may be considered. For an overview of lumbar disc options, see non-surgical lumbar disc treatment. Exercise continues after a procedure too: the procedure is there to help you get back to it.

If there is weakness or worsening nerve findings, a surgical opinion is sought. Our guide When is herniated disc surgery needed? explains when an operation is considered.

Symptoms that need urgent attention

Also see a doctor without delay if you have:

• pain together with fever or unexplained weight loss, or new back pain with a history of cancer
• severe pain that started after a fall or accident
• black, tarry stools, which can be a sign of stomach bleeding caused by pain relievers

To work out the right plan for you, you can request a consultation.