Tuesday, April 18, 2017

Non-Invasive Recommendations For Managing Low Back Pain

By Dr. R. Greg Lusk, DC

In January of this year a new clinical practice guideline was published in the European Journal of Pain with respect to the non-invasive management of low back pain (LBP).  A clinical practice guideline aims to summarize research evidence, with the goal of optimizing patient care and improving health outcomes, and to prevent clinicians from considering interventions that are ineffective, expensive or harmful.  LBP affects 80% of people throughout their lives, is a common cause of disability, and is the most common musculoskeletal complaint for which people visit a healthcare provider.  In more ways than one it is a very expensive condition that warrants guidance from best evidence.  For this particular guideline, over 2500 research titles and abstracts were reviewed with only 10 previously published guidelines being included due to quality.  The recommendations are as follows.
 
For Acute LBP (i.e. LBP that started suddenly or has only been present for a few days or weeks), or Chronic LBP (i.e. LBP that persists beyond 3 months), all 10 guidelines recommended:
 
1.    Advice, reassurance or education with evidence-based information regarding the expected course of recovery and effective self-care options (e.g. ice or heat for pain, short-term rest, medication).  With respect to course of recovery, most cases of LBP improve much or completely within six weeks of onset, with a slower rate of improvement noted beyond six weeks if it persists.  Recovery is also affected by risk factors such as job demands, sedentary lifestyle, body weight, age, and smoking.
 
2.    Acetaminophen (e.g. Tylenol) or NSAIDs (e.g. Advil) if indicated, with advice and consideration of risks and warning signs and symptoms.
 
For Acute LBP only, all guidelines encouraged an early return to activity, staying active, and the avoidance of prolonged bed rest.  A short course of muscle relaxants alone or in addition to NSAIDs if acetaminophen or NSAIDs did not reduce pain was also an option.  Spinal manipulation (i.e. spinal joint "adjustment") was also advised for those not improving with self-care methods.  Also, in rare cases when the pain is severe and unmanageable, short-term use of opioids was mostly recommended as long term use is associated with significant risk, something we have all become increasingly aware of due to the amount of media coverage on the topic.
 
For the management of Chronic LBP, other interventions recommended by all guidelines were exercise or yoga (for up to 12 weeks), manual therapy (i.e. spinal manipulation or mobilization) for up to 12 weeks, and extensive rehabilitation with both physical and psychological components over 8 weeks.  If acetaminophen or NSAIDs have not provided adequate pain relief, short-term use of opiods was also recommended taking into consideration side-effects, risks, and evidence of ongoing pain relief on re-assessment.  Massage, acupuncture, and antidepressant medication was also recommended by most guidelines.
 
Some interventions for Chronic LBP were also NOT recommended by most guidelines.  This does not mean these treatments don't provide relief, just that the supporting evidence isn't strong enough to warrant a recommendation.  This included the use of muscle relaxants, gabapentin (a medication for nerve-based pain), and passive electrotherapeutic modalities including TENS, laser, IFC, or ultrasound.
 
A key thing to remember with all of these interventions is that there are options and patient preference is an important consideration.  Some people want to avoid medications at all costs and others have no interest in having their low back manipulated.  For chronic LBP, results are often better with the inclusion of a more active component of treatment (e.g. exercise) but many patients admit that they will not comply with a regular program.  Thankfully the passive approaches still have value.
 
This article is for general information purposes only and is not to be taken as professional medical advice.