Dr. Jim provides evidence-based recommendations on the treatment of low back pain
Low back pain (LBP) is common. Most people experience at least one episode throughout their life. LBP ranks among the top five diagnoses seen by family physicians. Believe me I’ve seen hundreds if not thousands of cases over the past 30 years and for both patients and physicians the diagnosis and treatment can be challenging.
The causes of low back pain include muscular and tendon strain, disc degeneration, the so-called “ruptured disc,” traumatic injury, arthritis and spinal stenosis among others.
The treatment depends on diagnosis, which must include a comprehensive history, and thorough physical examination. Imaging studies may or may not be warranted, at least initially.
This post aims to provide readers insight into the evidence for the effectiveness of the multitude of therapies utilized to treat low back pain. I think you’ll be surprised and what I’m about to share with you has certainly changed my practice patterns.
Source of the Information Presented
An internationally recognized body of scholars known collectively as the Cochrane Collaboration provides thorough, scientific reviews on a host of healthcare issues. Their scholarly works are published as Cochrane Reviews. Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognized as the highest standard aka the gold standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation by comparing, analyzing and synthesizing the published research on a topic of importance – hence the term systematic review.
In the interest of space and time, I have introduced the treatment modality, a thumbnail of the author’s conclusion and the link to the article should readers want to read further. Enjoy!
Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica
Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches.
None-the-less it is evident that extended periods of bed rest are potentially harmful because they may lead to the deterioration of muscles and body functions and deep vein thrombosis.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007612.pub2/abstract
Behavioral treatment for chronic low-back pain
This review of 30 studies (3438 participants) evaluated three behavioral therapies for chronic low-back pain: (i) operant (which acknowledges that external factors associated with pain can reinforce it), (ii) cognitive (dealing with thoughts, feelings, beliefs, or a combination of the three, that trigger the pain), (iii) respondent (interrupts muscle tension with progressive relaxation techniques or biofeedback of muscle activity).
For pain relief, there was moderate quality evidence that:
(i) operant therapy was more effective than waiting list controls in the short-term,
(ii) there was little or no difference between operant therapy, cognitive therapy; or a combination of behavioral therapies in the short- or intermediate-term, and
(iii) behavioral treatment was more effective than usual care (which usually consists of physical therapy, back school and/or medical treatments) in the short-term.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002014.pub3/abstract
Combined chiropractic interventions for low-back pain
The authors included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.
The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and sub-acute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005427.pub2/abstract
Exercise therapy for treatment of non-specific low back pain
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In sub-acute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.
Injection therapy for sub-acute and chronic low-back pain
18 trials (1179 participants) were included in this updated review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender- and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics and a variety of other drugs.
Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy.
There is insufficient evidence to support the use of injection therapy in sub-acute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001824.pub3/abstract
Prolotherapy injections for chronic low-back pain
Prolotherapy involves repeated injections of irritant solutions to strengthen lumbosacral ligaments and reduce some types of chronic low-back pain; spinal manipulation and exercises are often used to enhance its effectiveness.
There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. When used alone, prolotherapy is not an effective treatment for chronic low-back pain. When combined with spinal manipulation, exercise, and other co-interventions, prolotherapy may improve chronic low-back pain and disability.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004059.pub3/abstract
Insoles for prevention and treatment of back pain
There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005275.pub2/abstract
Lumbar supports for prevention and treatment of low back pain
This review teased out the effect of lumbar supports into prevention and treatment
There was little or no difference between individuals with low-back pain who used back supports and those who received no treatment (five studies, 13,995 people), or education on lifting techniques (two studies).
In four studies (1170 people), there was little or no difference between patients with acute or chronic back pain who used back supports and those who received no treatment in short-term pain reduction or overall improvement. 54 people) in back pain prevention or reduction of sick leave.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001823.pub3/abstract
Massage for low-back pain
Authors included 25 trials (3096 participants) in this review update.
They concluded, there is very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up. There were only minor adverse effects with massage.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001929.pub3/abstract
Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain
The authors included 41 articles reporting on 25 RCTs with 4404 participants. Risk of bias was low in 16 studies. Three studies involved workers with acute back pain, eight studies workers with sub-acute back pain, and 14 studies workers with chronic back pain.
The main goal of physical conditioning as part of a return to work strategy, sometimes called work conditioning, work hardening or functional restoration and exercise programs, is to return injured or disabled workers to work or improve the work status for workers performing modified duties. Such programs may also simulate or duplicate work or functional tasks, or both, using exercises in a safe, supervised environment. These exercises or tasks are structured and progressively graded to increase psychological, physical and emotional tolerance and to improve endurance and work feasibility.
Results showed that light physical conditioning has no effect on sickness absence duration for workers with sub-acute or chronic back pain. We found conflicting results for intense physical conditioning for workers with sub-acute back pain.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001822.pub3/abstract
Spinal manipulative therapy for acute low-back pain
In this review, a total of 20 randomized controlled trials (RCTs) (representing 2674 participants) assessing the effects of SMT in patients with acute low-back pain were identified. Treatment was delivered by a variety of practitioners, including chiropractors, manual therapists, and osteopaths. Approximately one-third of the trials were considered to be of high methodological quality, meaning these studies provided a high level of confidence in the outcome of SMT.
Overall, we found generally low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008880.pub2/abstract
Spinal manipulative therapy for chronic low-back pain
Authors included 26 RCTs (total participants = 6070), nine of which had a low risk of bias.
Spinal manipulative therapy (SMT) is an intervention that is widely practiced by a variety of health care professionals worldwide. The effectiveness of this form of therapy for the management of chronic low-back pain has come under dispute. However, the results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy.
In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008112.pub2/abstract
Superficial heat for low back pain
Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application
There is moderate evidence that heat wrap therapy reduces pain and disability for patients with back pain that lasts for less than three months. The relief has only been shown to occur for a short time and the effect is relatively small. The addition of exercise to heat wrap therapy appears to provide additional benefit.
Surgical interventions for lumbar disc prolapse
Prolapsed lumbar discs (‘slipped disc’, ‘herniated disc’) account for less than five percent of all low-back problems, but are the most common cause of nerve root pain (‘sciatica’). Ninety percent of acute attacks of sciatica settle with non-surgical management. Surgical options are usually considered for more rapid relief in the minority of patients whose recovery is unacceptably slow.
Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001350.pub4/abstract
Traction for low-back pain with or without sciatica
Thirty-two clinical trials involving 2762 participants were analyzed in this review.
The included studies show that traction as a single treatment or in combination with physiotherapy is no more effective in treating LBP than sham (pretend) treatment, physiotherapy without traction or other treatment methods including exercise, laser, ultrasound and corsets. These conclusions are valid for people with and without sciatica. There was no difference regarding the type of traction (manual or mechanical).
Side effects were reported in seven of the 32 studies and included increased pain, aggravation of neurological signs and subsequent surgery. Four studies reported that there were no side effects. The remaining studies did not mention side effects.
These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003010.pub5/abstract
Transcutaneous electrical nerve stimulation (TENS)
Four high-quality randomized controlled trials (RCTs; 585 patients) comparing TENS with placebo for chronic low-back pain were included in this study. Due to conflicting evidence, it is unclear if TENS is beneficial in reducing back pain intensity. However, there was consistent evidence in two trials (410 patients) that TENS did not improve the level of disability due to back pain. There was moderate evidence that use of medical services and work status (e.g. loss of work, sick days) did not change during treatment. Finally, there did not seem to be a difference between conventional and acupuncture-like TENS.
Some adverse effects were reported, typically minor skin irritations observed equally in the treatment and placebo groups. However, there was one participant who developed a severe rash four days after the start of treatment.
In summary, the review authors found conflicting evidence regarding the benefits of TENS for chronic LBP, which does not support the use of TENS in the routine management of chronic LBP.
For further reading: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003008.pub3/abstract
So, what the heck is the bottom line when it comes to the treatment of low back pain? Based on the evidence presented here and my clinical experience here are my opinions and what I recommend to patients:
Surgery is a last resort and then only when it is clearly indicated and the surgeon is regarded as outstanding by his peers. Get a second opinion.
Stay active. Walk for 30 minutes 2 times daily, but avoid lifting or stooping over; standing is better than sitting.
Request a referral to physical therapy for guided home exercise (and do them).
Ask for a referral to behavioral therapy.
Use heat. It works!
Avoid opioid medications, especially for chronic pain. Who needs addiction?