What does the HAS say about treating low back pain?
For common low back pain, meaning pain with no red flags, the French National Authority for Health (HAS) makes exercise the main treatment (grade B). As first-line care, it recommends self-management and resuming daily activities, including work when possible, along with adapted physical activity and sports. Bed rest is not recommended: according to the Assurance Maladie, rest and inactivity can make the pain persist. Analgesics can relieve painful episodes, but none has been shown to be effective in the medium term on the course of an acute flare-up: their role is to relieve, not to cure.
Acute or chronic: two different approaches
Acute flare-up: reassure and maintain activity
In 90% of cases, common low back pain resolves favorably in less than 4 to 6 weeks (HAS). The clinician's role is to look for red flags, provide reassuring information about the prognosis, and encourage maintaining activity at the level pain allows. Worrying beliefs, such as the idea that pain signals danger, are among the risk factors for chronicity identified by the HAS. Imaging performed without red flags can reinforce them: it often reveals common findings, also frequent in people without pain, which cause worry without changing management. The HAS therefore does not recommend it during an acute flare-up, given the lack of a systematic correlation between images and symptoms.
Chronic low back pain: recondition
Beyond three months, low back pain is considered chronic. Fear of movement, avoidance behaviors, and the psychological, social, and occupational context then weigh on its course: the HAS recommends identifying them early and adopting a comprehensive, "biopsychosocial" approach. Treatment is based on therapeutic exercise adapted to the clinical situation, taught by a physical therapist and then continued at home, with the patient's active participation (grade B). Passive therapies used alone have no effect on the course of the condition. A 2021 Cochrane review of 249 trials concludes, with moderate certainty, that exercise is probably effective for pain compared with no treatment, usual care, or placebo. The World Health Organization (WHO) also includes structured exercise programs in its 2023 guideline on chronic low back pain.
Building the return to movement
- Assess: red flags, risk factors for chronicity ("yellow flags"), capacities, and apprehensions, following the method of functional rehabilitation. The HAS recommends reassessing the patient 2 to 4 weeks after an acute flare-up;
- Dose: start at the level pain allows, with gradual, split-up activity;
- Progress: increase load and range of motion in stages, with pain as a guide rather than a barrier;
- Maintain: according to the HAS, regular physical activity or self-administered exercises reduce the risk of recurrence (grade B).
Among musculoskeletal conditions, low back pain has the highest prevalence worldwide and is the leading cause of disability, according to the WHO. Its management can draw on exercise on prescription (France's "sport sur ordonnance" scheme) and adapted physical activity.
Frequently asked questions
Should you rest when you have back pain?
No. Bed rest is not recommended: according to the Assurance Maladie, rest and inactivity can make the pain persist. The HAS instead recommends self-management and resuming daily activities as soon as possible, then increasing them gradually.
What is the best exercise for low back pain?
Guidelines do not name one. The Assurance Maladie points out that there is no specific exercise routine for low back pain, and the HAS asks clinicians to take the patient's preferences into account. What matters is gradual, regular, adapted activity, hence the value of an individualized program.
Is an X-ray or MRI needed for low back pain?
Not during an acute flare-up without red flags (fever, major trauma, neurological deficit, deterioration in general health, etc.): the HAS does not recommend it, given the lack of a systematic correlation between images and symptoms. For chronic low back pain, beyond three months, the HAS does, however, recommend an MRI, even without red flags.
How long does a flare-up of low back pain last?
In 90% of cases, common low back pain resolves favorably in less than 4 to 6 weeks, according to the HAS. It recommends reassessing the patient 2 to 4 weeks after an acute flare-up.
When does low back pain become chronic?
After three months, according to the HAS definition. Low back pain that recurs within 12 months should also be considered at risk of chronicity. Management then relies on therapeutic exercise and a comprehensive physical, psychological, and socio-occupational approach.
Can low back pain be recognized as an occupational disease?
In France, occupational disease tables 97 and 98 of the general social security scheme recognize, under certain conditions, some chronic disorders of the lumbar spine, such as sciatica caused by a herniated disc, linked to whole-body vibration or to manual handling of heavy loads. In case of repeated sick leave or leave lasting more than 4 weeks, the HAS recommends involving the occupational physician.
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Editorial content intended to inform health professionals. It does not constitute individual medical advice and does not replace assessment by a professional.