Search for pain management in Bangkok and you will find clinics offering everything from pills and injections to massage, acupuncture, manipulation, machines and exercise. They can’t all be equally good.
This article compares the main options for three common problems: low back pain, neck pain and knee osteoarthritis. For each, it sets out what the best research and clinical guidelines say.
- Exercise and staying active have the best support across back pain and knee arthritis.
- Paracetamol and opioids did no better than placebo for new back pain in large trials.
- Anti-inflammatories help a little in the short term, with side effects to weigh up.
- Steroid injections for knee arthritis give short-term relief that fades within months.
- Guidelines recommend hands-on treatment only as part of an exercise plan.
- Machines such as ultrasound and TENS have little evidence of benefit for back pain.
A large review of low back pain care in The Lancet found that guidelines recommend education, a return to normal activity and exercise first. It also found that in practice, imaging, rest, opioids, spinal injections and surgery are used far more than the evidence supports [1].
Medicines
Paracetamol. In a trial of 1,652 people with new low back pain, those taking regular paracetamol recovered in a median of 17 days, the same as those taking it when needed. People taking a placebo recovered in 16 days [2]. NICE advises against paracetamol on its own for low back pain [3].
Anti-inflammatories (NSAIDs). These include ibuprofen, naproxen and diclofenac. For new low back pain, a Cochrane review found they reduced pain by about 7 points on a 100-point scale compared with placebo, an effect the authors called small and probably not clinically relevant [4]. Across back and neck pain, about 6 people need to take them for one to get a meaningful reduction in pain, and they raised the risk of stomach and gut side effects by 2.5 times [5]. NICE still lists them as an option for back pain, taking into account each person’s risks and using the lowest dose for the shortest time [3].
Opioids. The OPAL trial gave 347 people with new low back or neck pain either an opioid or a placebo for up to 6 weeks. At 6 weeks, pain was no better in the opioid group, and constipation was more common. The authors concluded that opioids should not be recommended for this kind of pain [6]. NICE also advises against opioids for chronic low back pain [3].
Injections
Steroid injections into the knee are a common option for osteoarthritis. A Cochrane review of 27 trials found a moderate benefit at 1 to 2 weeks, a small benefit at 13 weeks and no clear benefit at 26 weeks, with low-quality evidence throughout [7].
Repeating them doesn’t seem to build on that. In a two-year trial, 140 people with knee osteoarthritis had a steroid or saline injection every 12 weeks. The steroid group lost more cartilage, and knee pain was no different between the groups [8].
Exercise and staying active
Exercise has the most consistent evidence for long-standing pain. In chronic low back pain, a Cochrane review of 249 trials found that exercise reduced pain by about 15 points on a 100-point scale compared with no treatment, usual care or placebo, a clinically important difference [9].
For knee osteoarthritis, the latest Cochrane review covered 139 trials and 12,468 people. Exercise improved pain by about 13 points and function by about 12.5 points on 100-point scales compared with no exercise or usual care. The reviewers noted that the clinical importance of these gains is uncertain, but no other option in this article matches that body of evidence [10].
New back pain is different. Most of it improves within weeks [2], and a Cochrane review found that formal exercise therapy may make no clinically relevant difference in that early phase [11]. Here the advice is to keep moving and get back to normal activities as soon as you can [1].
Hands-on treatment
Spinal manipulation. A review of 47 trials with 9,211 people with chronic low back pain found that manipulation gave similar short-term pain relief to other recommended treatments, with a small extra improvement in function [12]. An updated Cochrane review in 2026 reached a similar conclusion [13].
Massage. A Cochrane review of 25 trials with 3,096 people said the reviewers had very little confidence that massage is an effective treatment for low back pain, with benefits mainly in the short term [14].
NICE’s position is that manual therapy, including manipulation, mobilisation and massage, should be considered only as part of a treatment package that includes exercise [3]. That matches how we use it: to settle pain enough to train, alongside an exercise plan. See manual therapy for more.
Acupuncture and dry needling
An analysis of individual patient data from 39 trials and 20,827 people found that acupuncture did better than no acupuncture for chronic pain, and slightly better than sham acupuncture. About 15% of the effect had faded at one year [15].
Guidelines don’t agree on how to use it. NICE advises against acupuncture for low back pain [3], but for chronic primary pain, such as fibromyalgia, it suggests considering a single short course of acupuncture or dry needling [16]. Read more on our dry needling page.
Machines: ultrasound, TENS and similar
Some clinics build sessions around machines. For low back pain, NICE advises against ultrasound, TENS and interferential therapy [3]. A Cochrane review of therapeutic ultrasound found little to no difference from placebo for short-term pain [17]. We don’t use these machines at Aspire Physio Bangkok, so session time goes into the treatments with better evidence.
Scans
NICE advises against routine imaging for low back pain in a non-specialist setting [3]. Scans of people with no back pain often show disc wear and bulges, and these become more common with age [18]. The Lancet review lists overuse of imaging among the main problems in back pain care [1]. A scan is worth having when a doctor suspects something specific.
How we approach pain at Aspire Physio Bangkok
We follow the evidence above. A physiotherapist assesses you, explains what is likely going on and builds a plan around graded exercise, with hands-on treatment or dry needling where it helps you train. Our gym is in the same building, so treatment carries through to the strength work that keeps pain from coming back.
See our pages on back pain, neck and shoulder pain, knee pain and sciatica and slipped disc. If you plan to claim on insurance, read how insurance works with us.
When to see a doctor first
For back pain, the NHS says to get emergency help if you have pain, tingling, weakness or numbness in both legs, loss of feeling around your genitals or bottom, or new problems controlling your bladder or bowels. The same applies if the pain started after a serious accident or comes with chest pain [19]. In Thailand, call 1669 for emergency medical help.
Otherwise, your first consultation with us is free. Book through our contact page or call 082-281-8009. We’re at Jasmine Building, 2nd Floor, Sukhumvit Soi 23, near Asok BTS.
Common questions
What is the best treatment for back pain?
Guidelines put staying active and exercise first, with hands-on treatment such as manipulation or massage only as part of a plan that includes exercise. Anti-inflammatories can be considered for short-term relief once their risks are weighed up. Paracetamol on its own is not recommended, and opioids are not recommended for chronic back pain and only rarely for new back pain.
Do I need a scan for back pain?
Usually not. NICE advises against routine imaging for low back pain. A scan is worth having when a doctor suspects a specific problem, such as a fracture, an infection or serious nerve compression.
Do steroid injections help knee arthritis?
They can ease pain for a week or two. In a Cochrane review the benefit was small by 13 weeks and gone by 26 weeks. A two-year trial of injections every 12 weeks found more cartilage loss and no difference in pain compared with saline.
Does acupuncture work for pain?
In a large analysis of 39 trials, acupuncture did better than no acupuncture and slightly better than sham acupuncture for chronic pain. Guidelines disagree on where to use it: NICE advises against it for low back pain but suggests considering a single course for chronic primary pain.
References
- Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. doi.org/10.1016/S0140-6736(18)30489-6
- Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-1596. doi.org/10.1016/S0140-6736(14)60805-9
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59. 2016, updated 2026. www.nice.org.uk/guidance/ng59/chapter/Recommendations
- van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. Cochrane Database Syst Rev. 2020;4(4):CD013581. doi.org/10.1002/14651858.CD013581
- Machado GC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017;76(7):1269-1278. doi.org/10.1136/annrheumdis-2016-210597
- Jones CMP, Day RO, Koes BW, et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023;402(10398):304-312. doi.org/10.1016/S0140-6736(23)00404-X
- Jüni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;(10):CD005328. doi.org/10.1002/14651858.CD005328.pub3
- McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975. doi.org/10.1001/jama.2017.5283
- Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. doi.org/10.1002/14651858.CD009790.pub2
- Lawford BJ, Hall M, Hinman RS, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2024;12(12):CD004376. doi.org/10.1002/14651858.CD004376.pub4
- IJzelenberg W, Oosterhuis T, Hayden JA, et al. Exercise therapy for treatment of acute non-specific low back pain. Cochrane Database Syst Rev. 2023;8(8):CD009365. doi.org/10.1002/14651858.CD009365.pub2
- Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. doi.org/10.1136/bmj.l689
- de Zoete A, Innocenti T, Petrozzi MJ, et al. Spinal manipulative therapy for adults with chronic low back pain. Cochrane Database Syst Rev. 2026;1(1):CD008112. doi.org/10.1002/14651858.CD008112.pub3
- Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD001929. doi.org/10.1002/14651858.CD001929.pub3
- Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain. 2018;19(5):455-474. doi.org/10.1016/j.jpain.2017.11.005
- National Institute for Health and Care Excellence. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline NG193. 2021. www.nice.org.uk/guidance/ng193/chapter/Recommendations
- Ebadi S, Henschke N, Forogh B, et al. Therapeutic ultrasound for chronic low back pain. Cochrane Database Syst Rev. 2020;7(7):CD009169. doi.org/10.1002/14651858.CD009169.pub3
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi.org/10.3174/ajnr.A4173
- NHS. Back pain. NHS website. www.nhs.uk/conditions/back-pain/
