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.
Even the nonprescription pain relievers are not risk free
Medicines like ibuprofen and naproxen can be helpful, but they can cause stomach inflammation and ulcers, as well as possible bleeding, and even kidney damage, especially in the elderly. Muscle relaxants can be sedating, and can interact with other common medications. Benzodiazepines and opiates not only can cause sedation, making it hard to think clearly and function normally, they are also addictive. Basically, for acute and subacute low back pain, the risks of these medications outweigh the benefits. Other medications, like acetaminophen, steroids, antidepressants, and anti-seizure medications, were not significantly helpful for acute and subacute low back pain at all.
Here’s what the study couldn’t tell us
The study was missing a few potentially helpful low-risk medicines. Topicals such as the lidocaine patch or capsaicin ointment were not included, which is a shame, as these can provide relief for some people, and carry little risk. I would also be interested to know if over-the-counter topical therapies containing menthol and camphor are better than placebo for low back pain. Suggestions for the future research, and the next update!
I plan to write about chronic low back pain (and chronic pain in general) in a future post, because there was a guideline update for that specific issue as well.
Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015, The Lancet, October 2016.
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Primary Care Office Insight at the Massachusetts General Hospital: Authors: Angela M. Freniere, MD and Shana Birnbaum, MD. MGH Primary Care Operations Improvement. Specialty Reviewer: Steven J. Atlas, MD, MPH.
Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. Journal of General Internal Medicine, February 2001.
Atlas SJ, Nardin RA. Evaluation and treatment of low back pain: an evidence-based approach to clinical care. Muscle & Nerve. January13, 2003.
Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain [Internet].Rockville (MD): Agency for Healthcare Research and Quality (US), 2016.
Qaseem, A, Wilt, T, McLean, R, Forciea, MA, for the Clinical Guidelines Committee of the American College of Physicians, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, February 14, 2017.
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Bible verses for today’s meditation and inspiration: Matthew E. McLaren
Psalm 38:3 There is no soundness in my flesh because of Your indignation; There is no health in my bones because of my sin.
Matthew 9:12-13 But when Jesus heard this, He said, “It is not those who are healthy who need a physician, but those who are sick. “But go and learn what this means: ‘I DESIRE COMPASSION, AND NOT SACRIFICE,’ for I did not come to call the righteous, but sinners.”
Luke 5:31-32 And Jesus answered and said to them, “It is not those who are well who need a physician, but those who are sick. “I have not come to call the righteous but sinners to repentance.”
Exodus 15:2 “The LORD is my strength and song, And He has become my salvation; This is my God, and I will praise Him; My father’s God, and I will extol Him.
Acts 3:16 “And on the basis of faith in His name, it is the name of Jesus which has strengthened this man whom you see and know; and the faith which comes through Him has given him this perfect health in the presence of you all.
Exodus 23:25 “But you shall serve the LORD your God, and He will bless your bread and your water; and I will remove sickness from your midst. Philippians 4:6-7
Be anxious for nothing, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.
Psalm 32:4-5 For day and night Your hand was heavy upon me; My vitality was drained away as with the fever heat of summer. Selah. I acknowledged my sin to You, And my iniquity I did not hide; I said, “I will confess my transgressions to the LORD”; And You forgave the guilt of my sin. Selah.
Psalm 149:4 For the LORD takes pleasure in His people; He will beautify the afflicted ones with salvation.
1 Thessalonians 5:9 For God has not destined us for wrath, but for obtaining salvation through our Lord Jesus Christ,
Titus 2:11 For the grace of God has appeared, bringing salvation to all men,
2 Peter 3:15 and regard the patience of our Lord as salvation; just as also our beloved brother Paul, according to the wisdom given him, wrote to you,
Revelation 12:10 Then I heard a loud voice in heaven, saying, “Now the salvation, and the power, and the kingdom of our God and the authority of His Christ have come, for the accuser of our brethren has been thrown down, he who accuses them before our God day and night.
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