Back Pain Page

Back Pain: So Many Treatments, So Little Science

A Review of the Evidence

Low back pain (LBP) reportedly occurs at least once in 85% of adults younger than 50 years, and 15-20% of Americans have at least one episode of back pain per year. Of these patients, only 20% can be given a precise reason. LBP resolves for the vast majority within 4 weeks. (http://emedicine.medscape.com/article/310353-overview)

The first steps in an evaluation of any patient with LBP involves a careful history and physical examination. There are a few specific causes that present with ‘red flags’ that need careful evaluation and vigilance by the practitioner. These red flags include: fever (could be a serious infection), change in bowel or bladder function (the nerves from the low spine may be compressed by a mass), trauma (could be a fracture), unexplained weight loss (a sign of cancer), history of cancer, and an abnormal neurologic exam (change in tone, strength or reflexes may indicate serious compression of the nerves), and persistence without improvement for over 4 weeks. If any of these red flags are present, then evaluation with an MRI or other high-tech procedures is warranted. 

However, high-tech procedures are all too often ordered even without these red flags, or worse, even without looking for them. In our era of available high-tech toys and limited health care dollars, this presents a real problem.

Are fancy diagnostic tools and treatments effective for most cases of LBP? The answer is surprisingly, “No”.

Back pain is one of those things that tend to wax and wane. We tend to seek care when symptoms are at their worst. The natural history is then to improve a bit. We often mistake the treatment as causing the pain to improve. Some treatments actually work, while others may not.

Let’s look at some common treatments that are practiced for LBP. Some are effective, some are not. Some are harmless, some are not. The scientific method is the only tool we have to sort this out.

Diagnosis

In the absence of any findings from the neurologic examination and with no evidence of infection or cancer, imaging studies (x-ray, MRI, CT) are not clinically helpful in the first 4 weeks of symptoms. No one has been helped by MRI if the red flags are not there. On the contrary, false positives are high in this situation which lead to unnecessary invasive procedures and risks. (http://emedicine.medscape.com/article/310353-workup#a0720)

MRI should be used only if infection, cancer, or persistent neurologic deficit is strongly suggested. The doctor is not necessarily ignoring you if he/she won’t order one.

Thermography is the detection of heat patterns from the body. It is investigational and the evidence to date is poor for its use. They should not be ordered. There are many practitioners out there that will try to sell patients thermograms, not just for diagnosing pain, but for detection of breast cancer instead of proven techniques like mammography. Thermography has no known role in the evaluation of mechanical LBP. If your practitioner orders one for you, find a new practitioner.

http://www.aetna.com/cpb/medical/data/1_99/0029.html

(http://emedicine.medscape.com/article/310353-workup#a0720)

Treatments

- Please note, the discussions below relate to common LBP and not to well-defined. surgical or medical causes such as severe herniated discs, fractures from trauma, spinal or urinary infections, bleeding or tumors.

Supportive care is all that is needed for most cases of acute LBP. As a self-limited condition, anything that can safely ease pain and not make matters worse will be helpful. As with many self-limited conditions, people tend to seek help when symptoms are at their worst. Therefore, any treatment or advise will seem to work.

Treatments that actually have some benefit are marked with a “Yes”.

Treatments with some benefit, but uncertain value are marked with a “Maybe” 

Treatments with little or no proven benefit are marked with a “No”.

Heat Application -Yes

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.http://www2.cochrane.org/reviews/en/ab004750.html

Cold Application - No

There is still not enough evidence about the effect of the application of cold for low-back pain of any duration, or for heat for back pain that lasts longer than three months.

http://www2.cochrane.org/reviews/en/ab004750.html

Muscle relaxers - Maybe

Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or non-steroidal anti-inflammatory drugs.

http://www2.cochrane.org/reviews/en/ab004252.html

Non-Steroidal Antiinflamatory Drugs - Maybe

The evidence from the 65 trials included in this review suggests that NSAIDs are effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica. However, effect sizes are small.

There is moderate evidence that NSAIDs are not more effective than other drugs for acute low-back pain.http://www2.cochrane.org/reviews/en/ab000396.html

Opioids - Maybe

Pooled results revealed that tramadol was more effective than placebo for pain relief.

One trial comparing opioids to another analgesic (naproxen) found opioids were statistically significant for relieving pain but not improving function. When re-calculated, the results were not statistically significant for either pain relief.

http://www2.cochrane.org/reviews/en/ab004959.html

Exercise - Yes

There is moderate quality evidence that post-treatment exercise programmes can prevent recurrences of back pain but conflicting evidence was found for treatment exercise.

http://www2.cochrane.org/reviews/en/ab006555.html

In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

Exercise therapy/ Physical Therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes,

http://www2.cochrane.org/reviews/en/ab000335.html

Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence.http://www.annals.org/content/142/9/776.short

Massage - Yes

Massage might be beneficial for patients with subacute (lasting four to 12 weeks) and chronic (lasting longer than 12 weeks) non-specific low-back pain, especially when combined with exercises and education.(http://www2.cochrane.org/reviews/en/ab001929.html)

Patient Education - Yes

Attending classes about back pain may help those with acute back pain and recurrent back pain.

For patients with acute or subacute LBP, intensive patient education seems to be effective. For patients with chronic LBP, the effectiveness of individual education is still unclear.

http://www2.cochrane.org/reviews/en/ab004057.html

Antidepressants - No

There is no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low-back pain. These findings do not imply that severely depressed patients with back pain should not be treated with antidepressants; furthermore, there is evidence for their use in other forms of chronic pain.

http://www2.cochrane.org/reviews/en/ab001703.html

Traction - No

We conclude that traction as a single treatment for LBP is probably not effective.

http://www2.cochrane.org/reviews/en/ab003010.html

Lumbar Supports - No

There is moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain, and conflicting evidence whether they are effective supplements to other preventive interventions. It remains unclear whether lumbar supports are more effective than no or other interventions for treating low-back pain.http://www2.cochrane.org/reviews/en/ab001823.html

TENS Units - No

TENS (Transcutaneous Electrical Nerve Stimulation) is a device that delivers electric current to stimulate nerves to relieve pain. Although it may be helpful in the pain from nerve disease (neuropathy), it is...” ineffective for the treatment of chronic low back pain (2 Class I studies).”

http://www.ncbi.nlm.nih.gov/pubmed/20042705

Injection Therapy - Maybe

There is insufficient evidence to support the use of injection therapy in subacute 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.

http://www2.cochrane.org/reviews/en/ab001824.html

Surgery (for osteoarthritis of the low spine) - Maybe

Evidence is not clear. Questionable risk benefit ratio.

Limited evidence is now available to support some aspects of surgical practice.(http://www2.cochrane.org/reviews/en/ab001352.html)

There is moderate evidence that instrumentation can increase the fusion rate, but any improvement in clinical outcomes is probably marginal. Only preliminary results are available on disc replacement and it is not possible to draw any conclusions on this subject.

The effectiveness of intra-discal electrotherapy (IDET) remains unproven.

Acupuncture - No

In a recent and large study comparing acupuncture to simulated acupuncture (in which patients were told that they were getting actual acupuncture, but in fact were having toothpicks twirled on their backs), there were no reported differences between the 2 groups. Both groups reported the same level of satisfaction. Both groups seemed happier than the “no treatment” control group. This indicates that any benefit from acupuncture comes from the (relaxing) ritual of the procedure, the belief on the part of the patient that something good is happening, and the special attention given to the patient by the caregiver.

The authors conclude that..”It remains unclear whether acupuncture or our simulated method ofacupuncture provide physiologically important stimulation or represent placebo or nonspecific effects. Arch Intern Med. 2009;169(9):858-866.

A review of all published data on acupuncture concludes that...”numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported.”

http://www.painjournalonline.com/article/S0304-3959(10)00689-5/abstract

What’s the harm? In the above sited review, “Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax (collapsed lung) and infections were the most frequently reported adverse effects.”

Low Level Laser Therapy - No

Three studies (102 people) reported that LLLT plus exercise were not better than exercise, with or without sham in the short-term in reducing pain or disability. Two studies (90 people) reported that LLLT was not more effective than exercise, with or without sham in reducing pain or disability in the short term. In other words, it doesn’t work. It does nothing. http://www2.cochrane.org/reviews/en/ab005107.html

Chiropractic - No (well, not so much anyway)

The comprehensive review, cited below, shows that “while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute 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. Any demonstrated differences were small and were only seen in studies with a high risk of bias.” (emphasis added)

(http://www2.cochrane.org/reviews/en/ab005427.html)

What is Chiropractic?

(The following are excerpts from an article by Dr. Steven Novella, neurologist at Yale University.)

Chiropractic was created in 1895 by Daniel David Palmer. The underlying principle of chiropractic is based upon the concept of Inate Intelligence, which is a vitalistic life force which originates in the brain and travels through the spinal cord and nerve to the rest of the body.

Chiropractic today is more diverse than in its origin. Only about 20% of chiropractors adhere rigidly to Palmer's subluxation theory of disease.

Only a small percentage of chiropractors have openly rejected the pseudoscientific ideas of their peers, such as Innate Intelligence, and have endorsed scientific principles, as well as appropriate medical ethics of restraint.

No significant research has been conducted into the central claims of chiropractic theory, which runs counter to modern concepts of physiology, anatomy, and disease. That clinical research which has been done has suffered from poor design and questionable outcomes, and yet have been grossly overrepresented by chiropractic organizations. Also, chiropractors ignore research which contradicts their strongly held beliefs.

http://www.hcrc.org/faqs/chiro.html

Available data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.(http://jrsm.rsmjournals.com/cgi/content/abstract/99/4/192

Chiropractic has been one of the most studied therapies for back pain. Unfortunately, the results are less than encouraging. Below is a comprehensive list of studies and reviews on the evidence for (and against chiropractic).

An independent review of NCCAM-funded studies of chiropractic.

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study

A randomised controlled trial of spinal manipulative therapy in acute low back pain (Ann Rheum Dis 2009)

A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain

Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.

A systematic review of systematic reviews of spinal manipulation

Spinal manipulative therapy for chronic low-back pain.

Combined chiropractic interventions for low-back pain (Cochrane)

Spinal manipulative therapy for low-back pain (Cochrane Review)

Spinal manipulative therapy for chronic low-back pain (Cochrane)

What’s the harm in Chiropractic/ Spinal Manipulative Therapy?

Vertebral Artery Dissection (Stroke caused by neck manipulation)

Spinal manipulation can cause life-threatening complications. Manipulation of the cervical spine, which has been associated with dissection of the vertebral artery,

appears to be especially dangerous.

http://classic-web.archive.org/web/20030408153930/http://medicalletter.org/freedocs/spinal.pdf

Neck And Spine Adjustments Linked To Increased Risk Of Stroke

Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.

SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.

http://www.neurology.org/content/60/9/1424.abstract

Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System February 2002

Conclusion

There are not really many effective treatments for common low back pain. Prevention is the key. Prevention may be achieved through healthy posture, proper lifting, maintaining a healthy body weight, not smoking and regular exercise. For more on prevention tips, click here.

The treatments that receive either a “Yes” or a “Maybe” are: 

- Heat

- Exercise/ Physical Therapy

- Massage Therapy

- Patient Education

- Muscle Relaxers*

- Non-steroidal Antiinflamatory Drugs*

- Opioids*

*Drugs must be used with extreme caution and can often cause more problems than they solve. When at all possible, non-drug treatment should be employed.

John Byrne, MD