Low back pain, the scourge of mankind: it is the second leading cause of disability here in the United States, and the fourth worldwide. It’s also one of the top five medical problems for which people see doctors. Almost every day that I see patients, I see someone with back pain. It’s one of the top reasons for lost wages due to missed work, as well as for healthcare dollars spent, hence, a very expensive problem.
Looking at two kinds of back pain
Let’s talk about the most common forms of back pain: acute (which lasts less than four weeks) and subacute (which lasts four to 12 weeks). Most of these cases (approximately 85%) are due to harmless causes. We lump them into the “mechanical back pain” diagnosis, which includes muscle spasm, ligament strain, and arthritis. A handful (3% to 4%) will be due to potentially more serious causes such as herniated discs (“bulging” discs), spondylolisthesis (“slipped” discs), a compression fracture of the vertebra due to osteoporosis (collapsed bone due to bone thinning), or spinal stenosis (squeezing of the spinal cord due to arthritis). Rarely, less than 1% of the time, we will see pain due to inflammation (such as ankylosing spondylitis), cancer (usually metastases), or infection.
When someone with acute low back pain comes into the office, my main job is to rule out one of these potentially more serious conditions through my interview and exam. It is only when we suspect a cause other than “mechanical” that we will then order imaging or labs, and then things can go in a different direction.
But most of the time, we’re dealing with a relatively benign and yet really painful, disabling, and expensive condition. How do we treat this? The sheer number of treatments is dizzying, but truly effective treatment options are few.
Analyzing a range of treatments for low back pain
The American College of Physicians (ACP), the second-largest physician group in the U.S., recently updated guidelines for the management of low back pain. Its physician researchers combed through hundreds of published studies of non-interventional treatments of back pain, and analyzed the data. Treatments included medicines such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen), opioids (such as oxycodone), muscle relaxants, benzodiazepines (such as lorazepam and diazepam), antidepressants (like fluoxetine or nortriptyline), anti-seizure medications (like Neurontin), and systemic corticosteroids (like prednisone). The analysis also included studies on non-drug treatments including acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (working the muscles that support and control the spine), progressive relaxation, biofeedback, low-level laser therapy, behavior based therapies, or spinal manipulation for low back pain.
That’s a lot of therapies!
Researchers were interested in studies that measured the effectiveness (usually measured as pain relief and physical functioning) as well as the harms of all these therapies.
Drugs are not part of the latest recommendations for treating “mechanical” back pain
What the researchers found was surprising: for acute and subacute low back pain, the best and safest treatments are not medicines. The ACP made the following strong recommendation:
Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.
Because most mechanical back pain improves no matter what, we don’t want to prescribe treatment that can cause harm. Because some medications carry significant risks, we really shouldn’t be recommending these right off the bat. Rather, we should be providing guidance on heating pad or hot water bottle use, and recommendations or referrals to acupuncturists, massage therapists, and chiropractors. These therapies were somewhat effective, and are very unlikely to cause harm.
Bible verses for today’s meditation and inspiration: Matthew E. McLaren
Genesis 39:23 The chief jailer did not supervise anything under Joseph’s charge because the LORD was with him; and whatever he did, the LORD made to prosper.
Joshua 1:7 “Only be strong and very courageous; be careful to do according to all the law which Moses My servant commanded you; do not turn from it to the right or to the left, so that you may have success wherever you go.
2 Chronicles 20:20 They rose early in the morning and went out to the wilderness of Tekoa; and when they went out, Jehoshaphat stood and said, “Listen to me, O Judah and inhabitants of Jerusalem, put your trust in the LORD your God and you will be established. Put your trust in His prophets and succeed.”
2 Chronicles 26:5 He continued to seek God in the days of Zechariah, who had understanding through the vision of God; and as long as he sought the LORD, God prospered him.
Ecclesiastes 11:6 Sow your seed in the morning and do not be idle in the evening, for you do not know whether morning or evening sowing will succeed, or whether both of them alike will be good.
Proverbs 16:3 Commit your works to the LORD And your plans will be established.
Esther 8:15 Then Mordecai went out from the presence of the king in royal robes of blue and white, with a large crown of gold and a garment of fine linen and purple; and the city of Susa shouted and rejoiced.
Deuteronomy 29:9 “So keep the words of this covenant to do them, that you may prosper in all that you do.
Psalm 118:25 O LORD, do save, we beseech You; O LORD, we beseech You, do send prosperity!
Proverbs 15:22 Without consultation, plans are frustrated, But with many counselors they succeed.
Proverbs 21:30 There is no wisdom and no understanding And no counsel against the LORD.
Acts 5:34-39 But a Pharisee named Gamaliel, a teacher of the Law, respected by all the people, stood up in the Council and gave orders to put the men outside for a short time. And he said to them, “Men of Israel, take care what you propose to do with these men. “For some time ago Theudas rose up, claiming to be somebody, and a group of about four hundred men joined up with him. But he was killed, and all who followed him were dispersed and came to nothing.
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