The guidelines on low back pain are clear—drugs and surgery should be the last resort

Most people with low back pain aren’t getting the most effective treatment. Credit: shutterstock.com

Low back pain is the leading cause of disability worldwide and is becoming more common as our population ages. Most people who have an episode of low back pain recover within six weeks, but two-thirds still have pain after three months. By 12 months, pain may linger but is usually less intense.

17 may 2018--Still, recurrence is common and in a small number of people it may become persistent and disabling. Chronic back pain affects well-being, daily functioning and social life.
A series on low back pain by the global medical journal The Lancet outlined that most sufferers aren't getting the most effective treatment. The articles state that recommended first-line treatments – such as advice to stay active and to exercise – are often overlooked. Instead, many health professionals seem to favour less effective treatments such as rest, opioids, spinal injections and surgery.
So, here's what evidence shows you need to do to improve your low back pain.
Risk factors for low back pain
The cause of most people's low back pain remains unknown. But we do know of a number of risk factors that could increase the chance of developing low back pain. These include a physically demanding job that involves lifting, bending and being in awkward postures. Lifestyle factors such as smoking, obesity and low levels of physical activity are also associated with developing low back pain.
People with low back pain should see a health professional to rule out the more serious causes of pain such as fracture, malignancy (cancer) or infection.
Once patients are cleared of these, the current guidelines from Denmark, the UK and the US advise self-management and psychological therapies as the initial response for persistent low back pain. These include staying active, doing appropriate exercises and undertaking a psychological program to help manage the pain.
Exercises such as Tai Chi, yoga, motor control (to restore strength, co-ordination and control of the deep core stabilising muscles supporting the spine) and aerobic exercises (such as walking, swimming, cycling and general muscle reconditioning exercises) are recommended.
If any of these therapies fail or stop working, the guidelines point to manual and physical therapies such as spinal manipulation (Denmark, UK, US), massage (UK and US) and yoga and acupuncture (US) – particularly for low back pain lasting more than 12 weeks.
Exercise and psychological therapy
The guidelines are based on many studies that have shown the benefits of exercise and psychological therapies. For instance, a 2006 study compared pain levels across two groups of physically active people with chronic low back pain.
Participants who followed a four-week program using Pilates exercise equipment reported a more significant reduction in pain and disability than those in a control group who received usual care (consultations with a health care professional as needed). The benefit for the exercise group was maintained over a 12-month period.

Credit: The Conversation

Another, 2011 trial explored the benefits of Tai Chi for those with persistent low back pain. Participants who completed a ten-week course of Tai Chi sessions had less bothersome back symptoms, pain intensity and self‐reported disability, compared with a control group who continued with their normal medical care, fitness or health regimen.
Chronic pain is linked with chemical and structural changes at all levels of the nervous system. These include the level of neurotransmitter changes that alter pain modulation, and sensitisation of the nerves involved in transmitting pain signals. Incoming pain signals can be modified by our response to persistent pain.
Psychological treatments – such as mindfulness-based stress reduction – focus on increasing awareness and acceptance of physical discomfort, as well as challenging emotions often associated with chronic pain.
In a trial including 342 participants, around 45% of those who had completed eight sessions of cognitive behaviour therapy or mindfulness-based stress reduction had clinically meaningful improvements in bothersome pain at 26 weeks of follow-up. This was compared to only 26.6% of people who had received usual care.
Manual therapy
In Australia, physiotherapists, chiropractors and osteopaths use manual and physical therapy to treat lower back pain. The treatments often include some form of spinal manipulation and massage, as well as advice to stay active and do exercises. This is consistent with The Lancet's recommendations, also based on evidence from studies.
A 2013 trial of people with acute low back pain compared the effects of spinal manipulation with those of the non-steroidal anti-inflammatory drug diclofenac (Voltaren) and placebo on their pain. Spinal manipulation was found to be significantly better than diclofenac and clinically superior to placebo in reducing disability, pain and the need for rescue medication. It was also found to improve quality of life.
Similar results came from another study of 192 people with low back pain that lasted around two to six weeks. Participants were randomly allocated to one of three groups: chiropractic manipulation with a placebo medication; muscle relaxants with sham manipulation; or placebo medicine with sham manipulation. All subjects improved over time, but the chiropractic group responded significantly better, with a bigger decrease in pain scores, than the control group.
Physiotherapists, chiropractors and osteopaths are required by law to be registered with the Australian Health Practitioner Regulation Agency (AHPRA) to practise in Australia. To be registered, a person must complete a minimum of four years' study at a university in a degree that includes a focus on non-pharmacological (drug-based), non-surgical management of musculoskeletal conditions, including low back pain.
Under the government's Chronic Disease Management Plan patients with persistent low back pain may be referred to physiotherapists, chiropractors or osteopaths for evidence-based therapies such as spinal manipulation and massage. If patients are unfamiliar with these therapies, they can discuss referral with their GP.
Physiotherapists, chiropractors and osteopaths can also be consulted without referral. Their services are usually covered by private health insurance. The AHPRA website lists registered practitioners in your area.
One thing to look out for when you see a practitioner is the number of treatments they recommend. Patients usually start with a short course of two to six treatments to see if the treatment helps. It shouldn't take many treatments for a change in symptom pattern to become obvious.
The message to the public and to health professionals is clear. People with non-specific low back pain need to learn how to independently manage their pain while remaining active, staying at work and maintaining their social life as far as possible.

This article was originally published on The Conversation. Read the original article.

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Multidisciplinary approach successful in chronic back pain

16 feb 2015—Medication combined with a multidisciplinary rehabilitation program can decrease disability and improve mental health in low back pain patients over several years, according to a study published online Dec. 26 in the International Journal of Rheumatic Diseases.

Sedigheh S. Tavafian, Ph.D., from Tarbiat Modares University in Tehran, Iran, and colleagues conducted an extended 30-month follow-up of participants of a clinical trial evaluating group-based rehabilitation plus drug treatment for low back pain. In the follow-up, 69 patients in the intervention group continued receiving monthly motivational consultation and booster classes plus oral medication, and 77 patients in the control group received medication alone.

The researchers found that the two groups showed improvement for all studied variables (evaluated using the Short Form 36, Quebec Disability Scale [QDS], and Ronald Morris Disability Questionnaire [RDQ]) over time up to 30 months. However, the intervention group had consistently better outcomes for all variables compared with the control group. Within each group there were significant differences by time for measures of mental health and disability measured through QDS and RDQ.

"The proposed multidisciplinary program could improve mental health and disability up to 30 months in chronic low back pain patients," the authors write.

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Yoga Effective in Treating Chronic Low Back Pain

Less disability, pain and depression when patients do yoga regularly

09 sept 2009-- Patients with chronic low back pain derive better results in terms of reduced functional disability, pain and depression when they do a 24-week course of yoga compared with standard medical care, according to a study in the Sept. 1 Spine.

Kimberly Williams, Ph.D., of West Virginia University in Morgantown, and colleagues conducted a study of 90 subjects with chronic low back pain, of whom 43 were randomized to participate in a 24-week, biweekly course of Iyengar yoga sessions, while the 47 subjects in the control group received standard medical care.

The researchers assessed the outcome of the two treatment arms after 12, 24 and 48 weeks, and found that clinical improvements were reported at 12 and 24 weeks by a significantly larger proportion of the yoga group than the group receiving standard care, and these subjects also had significantly reduced functional disability at 24 weeks. The authors further note that the yoga group subjects also reported less depression.

"The majority of participants (82 percent) completed the 24-week therapeutic Iyengar yoga intervention, and, as hypothesized, the intervention was effective and efficacious in treating chronic low back pain when compared to standard medical care," Williams and colleagues conclude. "There was also a clinically important trend for the yoga group to reduce their pain medication usage compared to the control group."

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Aquatic Exercise May Be Helpful for Low Back Pain

Subjects in water-based program showed better improvements than those in land-based program

28 june 2009-- Exercising in water may be particularly beneficial for people with chronic low back pain, according to research published in the June 15 issue of Spine.

Umit Dundar, M.D., of the Kocatepe University in Afyonkarahisar, Turkey, and colleagues analyzed data from 65 adults, ages 20 to 50 years, with low back pain of more than three months' duration. They were randomized to participate in 20 sessions of an aquatic exercise program over four weeks or a self-directed land-based program for four weeks.

The researchers report that both groups showed improvements on a variety of outcomes, including pain measured on a visual analog scale; disability (measured on the modified Oswestry low back disability questionnaire); and quality of life (measured with the Short Form-36 Health Survey). However, at weeks four and 12, the aquatic group showed better improvement on the Oswestry questionnaire and the physical function and role limitations due to physical functioning sections of the Short Form-36.

"Movement in water is often less painful than similar movement on land. Sensory input from water pressure and temperature may decrease feelings of pain. A desired exercise intensity can be achieved by adjusting the velocity of movement in the water. Water-based physical activity enhances balance and coordination, while stimulating, visual, vestibular, and perceptual systems. Buoyancy reduces stress on joints and muscles and enables greater range of movement via supporting the weight of the body," the authors write.

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NSAIDs, Acetaminophen Equivalent in Relieving Low Back Pain

By Michael Smith
ROTTERDAM, The Netherlands, Jan. 23 -- For lower back pain, the old standby acetaminophen appears to be as effective for pain relief as nonsteroidal anti-inflammatory drugs (NSAIDs), researchers here said.
A meta-analysis of 65 studies of NSAIDS for lower back pain, with or without sciatica, showed the drugs are more effective than placebo but roughly equivalent to acetaminophen, according to a systematic review published in the first 2008 issue of The Cochrane Library.
But NSAIDs have significantly more side effects -- mainly gastrointestinal -- than acetaminophen, with a relative risk of 1.76 (with a 95% confidence interval from 1.12 to 2.76), the researchers found.
The findings support guidelines that suggest NSAIDs be used only after acetaminophen (also known in Europe as paracetamol) has been tried, "since there are fewer side effects with paracetamol," said lead author Pepijn Roelofs, a doctoral student at Erasmus University in Rotterdam, Holland, and colleagues.
The report is an undated version of a review first published in 2002. It includes 15 new studies, the researchers said. Of the 65 evaluated studies, which enrolled 11,237 patients, 28 (or 42%) were considered high quality.
The 65 studies compared NSAIDs to placebo, acetaminophen, muscle relaxants, and other drugs, non-drug treatments, and other NSAIDs, the researchers said.
They looked at 11 studies comparing NSAIDS to placebo in acute low back pain and four in chronic pain.
For acute pain, the studies were heterogeneous, but there was enough information to conclude that NSAIDs were more effective than placebo, with a pooled relative risk for global improvement after one week of 1.19, with a 95% confidence interval from 1.07 to 1.33.
The effect sizes seen in the individual studies were also small, the researchers noted.
On the other hand, there was no significant difference if the patients were suffering from sciatica.
Side effects were more common in patients getting NSAIDs, with a pooled relative risk of 1.35 (with a 95% confidence interval from 1.09 to 1.68).
For chronic pain, NSAIDs also significantly reduced pain (P<0.00001), but had significantly more side effects (pooled relative risk of 1.24, with a 95% confidence interval from 1.07 to 1.43).
Only seven studies compared one or more types of NSAIDs with acetaminophen, the researchers found and they provide "moderate evidence" that the two forms of medication are equivalent in reducing acute low back pain, the researchers said.
But, they said, there's "limited evidence" -- a single study -- showing NSAIDs to be more effective in treating chronic pain.
The analysis also found:
"Moderate evidence" that NSAIDs are no more effective than other drugs for acute low back pain.
"Strong evidence" that various types of NSAIDs, including the controversial cyclooxygenase-2 inhibitors (COX-2), are equally effective for acute low back pain.
The COX-2 NSAIDs, in these studies, had significantly fewer side effects than traditional NSAIDs. The pooled relative risk was 0.83, with a 95% confidence interval from 0.70 to 0.99.
The researchers noted that the COX-2 inhibitors have been enveloped with controversy over long-term cardiovascular side effects.
"It might well be," they argued, "that in the majority of patients with low back pain, the intake is of short duration and might not reach the level associated with increased cardiovascular risks."
The benefit of the medications "varies from individual to individual," said Jon Levine, M.D., of the University of California San Francisco, who was not affiliated with the review.
"If one NSAID does not work, you can try another," he said in a statement. "This is often a very empirical situation. If it takes care of the pain, wouldn't you take it?"
The study was supported by the Dutch Health Insurance Board.
The researchers did not report any potential financial conflicts.
Primary source: Cochrane Database of Systematic ReviewsSource reference:Roelofs PDDM, et al "Non-steroidal anti-inflammatory drugs for low back pain" Cochrane Database of Systematic Reviews 2008; Issue 1: DOI: 10.1002/14651858.CD000396.pub3.

Guidelines Issued for Management of Low Back Pain

October 2, 2007 — The American College of Physicians (ACP) and the American Pain Society (APS) have issued a comprehensive joint clinical practice guideline for the diagnosis and treatment of low back pain, which is published in the October 2 issue of the Annals of Internal Medicine. These guidelines offer recommendations concerning how to categorize patients, when to perform imaging studies, educational information for patients, self-care, when to prescribe medications and what types, and nonpharmacologic therapy. An important caveat is that clinicians should not routinely order imaging and other diagnostic tests.
"There are many options for evaluation and treatment of low back pain," second study author Amir Qaseem, MD, PhD, MHA, senior medical associate in the ACP Department of Clinical Programs and Quality of Care in Philadelphia, Pennsylvania, said in a news release. "We wanted to review all the evidence and develop guidance for clinicians and to give our patients a realistic sense of what they can expect when they visit a clinician for low back pain. It is important to tell patients about their expected course based on evidence-based information and advise them to remain active."
In the United States, several studies suggest that approximately 25% of adults report having had low back pain in the past 3 months, whereas 7.6% report at least 1 episode of severe acute low back pain within the previous year. Clinical evidence suggests that regardless of treatment, most low back pain improves within 1 month. Available treatment options range from watchful waiting to conservative treatment with pharmacologic and nonpharmacologic modalities to invasive procedures such as spinal surgery.
The impetus for the creation of these guidelines was a meeting of a multidisciplinary panel of experts convened in 2006 by ACP and APS. Their mission was to develop questions and the scope of an evidence report on low back pain, to review the available evidence in this field, and to generate recommendations assisting primary care clinicians in diagnosing and treating low back pain.
The joint ACP-APS guidelines target primary care physicians and other clinicians, rather than anesthesiologists, interventional radiologists, orthopaedists, or neurosurgeons. Although these guidelines do not address invasive therapies performed by specialists, the APS plans to publish a separate guideline in 2008 that will describe the use of invasive procedures for low back pain.
The current joint ACP-APS recommendations provide an algorithm to facilitate collection and interpretation of data during the first patient visit and to categorize patients into 1 of 3 general subgroups: (1) nonspecific low back pain (accounts for 85% of patients); (2) back pain potentially associated with spinal conditions, such as spinal stenosis, sciatica, and vertebral compression fracture; and (3) back pain potentially associated with another specific cause, such as cancer.
For patients with nonspecific low back pain, clinicians should not routinely order imaging studies, including radiographs, computerized tomography (CT) scans, magnetic resonance imaging (MRI), or other diagnostic tests. These tests should be used to evaluate only those patients who have severe or progressive neurologic deficits or who are suspected to have cancer, infection, or other underlying condition as the cause of their low back pain.
The guidelines are accompanied by 2 background articles reviewing the evidence underlying the recommendations for pharmacologic and nonpharmacologic treatment options for acute and chronic low back pain.
"Almost all medications reviewed had some benefits, but they have risks," said lead study author Roger Chou, MD, head of the APS Clinical Practice Guidelines Program. "Acetaminophen, for example, is very safe but might not be effective. NSAIDs [nonsteroidal anti-inflammatory drugs] have gastrointestinal and cardiovascular risks."
Specific recommendations in the guidelines are as follows:
Focused history and physical examination should help categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. Evaluation of psychosocial risk factors is essential during history taking because these predict the risk for chronic disabling low back pain (strong recommendation; moderate-quality evidence).
For patients with nonspecific low back pain, clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence).
Patients with severe or progressive neurologic deficits, or in whom history and physical examination suggest cancer, infection, or other underlying condition as the cause of their low back pain, should undergo imaging studies and other appropriate diagnostic tests (strong recommendation; moderate-quality evidence).
Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if positive results would potentially lead to surgery or epidural steroid injection for suspected radiculopathy. In choosing an imaging procedure, MRI is preferred to CT (strong recommendation; moderate-quality evidence).
Patient education by clinicians should include provision of evidence-based information on low back pain. Topics that should be covered include expected course and effective self-care options. Clinicians should also counsel their patients to stay physically active (strong recommendation; moderate-quality evidence).
When pharmacotherapy is considered, drugs of choice should be those with proven benefits, and they should be used together with self-care and back care education. Before starting a patient on pharmacotherapy, clinicians should evaluate pain and functional deficits at baseline. They should also review the risk-benefit ratio of specific medications before prescribing them and should consider the relative lack of long-term efficacy and safety data (strong recommendation; moderate-quality evidence). Acetaminophen or NSAIDs are preferred first-line drugs for most patients.
When self-care options do not result in improvement, clinicians should consider adding nonpharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation; moderate-quality evidence).
"Opioids and muscle relaxers can provide relief for those with severe pain, but their potential benefits and risks should be weighed carefully," Dr. Chou said. "Patients who prefer not to take medication can benefit from non-drug treatments, such as acupuncture, spinal manipulations, and massage therapy. None, however, are proven to be more effective than others to warrant recommendation as first-line therapy."
Dr. Chou has disclosed receiving an honorium from Bayer Healthcare Pharmaceuticals. One of the authors has disclosed financial relationships with Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Novo Nordisk, Pfizer, Merck, Bristol-Myers Squibb, Atlantic Philanthropics, and Sanofi-Pasteur.
Ann Intern Med. 2007;147:478-491.