Low Back Pain: What Works

A new study published in JAMA this month finds that treating low back pain early, with physical therapy, does not lower pain scores or raise quality-of-life scores in patients with back pain for less than 16 days. Although there was a small, statistically significant difference of three points in the mean disability score of those treated with PT and those receiving usual care, it was not considered a clinically meaningful improvement.

Early PT ineffective

In the study of approximately 200 adults, “usual care” was comprised largely of patient education, including advice to remain active. All of the subjects received usual care; about half also received four physical therapy sessions over three weeks. PT was comprised of spinal manipulation and exercise. Going into the study, patients had registered a disability score of 20 points or higher, on a 100-point scale. All had no symptoms below the knees.

After three months, in addition to the modest, less than meaningful drop in disability scores, the groups mostly did not differ in their need for healthcare, or in pain and quality-of-life scores. The study suggests that there is no value to early PT intervention in patients with low back pain.

Evidence-based treatment

Several years ago, the American College of Physicians and the American Pain Society jointly published clinical practice guidelines on the diagnosis and treatment of low back pain. Familiarity with these may shed light on what is most effective, and therefore what sufferers of low back pain can look to do to some extent on their own to improve outcomes.

The first of the recommendations is, not surprisingly, a thorough patient physical exam including questions about history, including any “psychosocial risk factors” for chronic, disabling back pain.

  • A physical exam/history can help categorize the source of your back pain as:
    • Nonspecific: Is it impossible to pinpoint a single cause?
    • Radiculopathy: Is the source of the pain an injured nerve root?
    • Spinal stenosis: Is it a narrowing of the bone channel occupied by the spinal nerves?
    • Other: Is it another specific cause?

  • Next, your doctor should not routinely obtain imaging or perform other diagnostic tests if your back pain is categorized as nonspecific.

  • On the contrary, if serious underlying conditions are suspected, imaging and other relevant diagnostic testing are warranted. Such conditions include any severe or progressive functional abnormality due to a decrease in function of the nerves or muscles.

  • It is appropriate for your doctor to schedule an MRI to evaluate persistent pain, radiculopathy or spinal stenosis only when you are being considered for surgery or epidural steroid injection.

  • Remain active to the extent your back pain allows.

  • Apply superficial heat for relief.

  • NSAIDs, including ibuprofen (Advil) can relieve pain and reduce inflammation. Acetaminophen (Tylenol) may be effective too, but is not an NSAID—only an analgesic. Depending on pain severity and physical dysfunction, you may consider taking one or the other as a first-line medication.

  • These drugs are not recommended for long-term use.

  • Though recently shown to be of negligible effect in the early stages of low back pain, you might have luck with spinal manipulation for acute pain if you don’t improve after the initial self-care steps listed above. Exercise therapy, yoga and progressive relaxation techniques may also provide relief.

  • If your back pain persists, consider cognitive behavioral therapy to help manage it. CBT can help you adjust your thinking about your chronic pain. Mind-management of pain works by breaking the cycle of negative thoughts—changing “I can’t do anything anymore” to “I’ve gotten through this before and can do it again.”

The recommendations here are based on systematic reviews of the available evidence. The guidelines don’t cover the surgical management of low back pain. NEJM Journal Watch notes in its analysis of the recommendations that within these reviews, there is evidence that skeletal muscle relaxants for acute pain may also be effective. Antidepressants may help in severe cases, where CBT has been insufficient to ease the depression and anxiety that can overwhelm people with chronic low back pain.

JAMA, 2015, Vol. 314, No. 14, pp. 1459-1467, http://jama.jamanetwork.com/article.aspx?articleid=2456165

Ann. Intern. Med., 2007, Vol. 147, No. 7, pp. 478-505, http://annals.org/article.aspx?articleid=736814

NEJM Journal Watch, Oct. 25, 2007, “Diagnosis and Treatment of Low Back Pain,” by Richard Saitz, MD

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