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.
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