Guidelines For The Treatment Of Low Back Pain - What The Experts Recommend

Low back pain is a musculo-skeletal condition that is a leading cause of disability and it has a major impact on our society. It also costs both individuals and companies a lot of money in terms of treatment expenses and lost productivity. With rising levels of inflation and many people struggling to make ends meet, finding ways to manage low back pain in a cost-effective way is more important than ever.



Woman with low back pain


Cost Of Low Back Pain


Low back pain costs consumers, and the economy, a lot of money and costs are rising at an even faster pace than overall healthcare spending. What’s more, these costs don’t always produce results for customers. Although there are more solutions available than ever before, research suggests that improved outcomes for people are not increasing.


In 2018, the highly respected medical journal, the Lancet, published a series of articles that called for the improvement of care for managing low back pain. The various authors spoke about the importance of having evidence-based solutions and more uniform care for this pervasive problem.



treatment recommendations have spoken against the use of medications for pain management since 2012.

When it comes to the management and treatment of low back pain, unfortunately there has been little agreement on the best solutions for patients. While treatment recommendations have spoken against the use of medications for pain management since 2012, many low back pain sufferers continue to be prescribed opioids or other pain management medications. Rest and imaging also continue to be recommended even though the evidence seems to go against these treatments for the majority of low back pain sufferers.


To this end, various healthcare professionals around the world have formed workgroups to review the vast amount of scientific data and literature around some of these treatment options to see what is really working for patients and what needs further investigation. These workgroups also look at things like cost-effectiveness and the potential harm that some of these products can cause. It is not helpful if a product is effective but not safe.


This article takes a look at some of the most common questions around treatment and looks at the recommendations provided by these working groups.



Chronic low back pain is recognized as lasting more than 12 weeks.


When Should I Seek Care For Low Back Pain?


Low back pain is most commonly defined into two or three main categories. The first category is acute low back pain that is generally defined as lasting less than 4 weeks. The second category is Subacute low back pain and it typically lasts between 4 to 12 weeks. The final category is chronic low back pain which is recognized as lasting more than 12 weeks.


Not only do many patients with acute low back pain not reach out for medical treatment, but many will wait for the pain to resolve on its own (which it often does) or self-medicate with home remedies and over the counter medications. While it certainly does not hurt to check in with your healthcare provider when you have an experience of low back pain, if your pain lasts more than 12 weeks you should definitely have your condition reviewed by your primary care doctor.



Diagnostic imaging for low back pain is often ineffective and unhelpful.


How Is Low Back Pain Assessed?


One of the first things that low back pain sufferers hear is, “Let’s get an MRI or an x-ray so we can see what is going on”. While this can often sound reassuring to patients, diagnostic imaging is often ineffective and unhelpful. Due to the nature of the condition diagnostic imaging often does not detect the cause of the pain and can actually detect other conditions that may have no impact on low back pain at all.


The North American Spine Society actually talks about the negative costs associated with diagnostic imaging for low back pain. It is their belief that, in some cases, “financial incentives actually affect the clinical decision to refer a client for imaging. Physician ownership of diagnostic or treatment facilities could theoretically increase rates of referral and utilization”. They go on to say that “in the case of patients with LBP, early or frequent ordering of diagnostic imaging or of therapeutic interventions when not clearly indicated could produce higher overall costs in the care of these patients”.



The presence of certain “red flags” or particular medical issues should trigger the use of diagnostic imaging for low back pain.


Obviously there are certain situations where imaging is required for the management of low back pain. The presence of certain “red flags” or particular medical issues should trigger the use of diagnostic imaging to rule out more serious conditions that may be associated with low back pain.


Ideally, when patients end up seeking medical care for their low back pain, doctors should take a detailed medical history and perform a thorough physical examination.



When it comes to treating low back pain, the experts all agree that nonpharmacologic treatment is the way to go.


How Do I Treat Low Back Pain?


When it comes to treating low back pain, the experts all agree that nonpharmacologic treatment is the way to go. Nonpharmacologic treatment refers to treatments that don’t include medication. For acute low back pain that includes things like superficial heat therapy, massages, spinal manipulation or acupuncture.


When looking at chronic lower back pain, experts often recommend multidisciplinary treatments like yoga, tai chi, exercise, biofeedback, cognitive behavioral therapy (CBT), and mindfulness-based stress reduction (MBSR). These treatments are generally cost effective and safe for most individuals, plus they have clinical studies to support their effectiveness in helping to reduce low back pain.



Opioids are less than 30% effective for treating pain that isn’t related to cancer.

Can I Use Medications For My Low Back Pain?


Pain is very subjective and it is very personal. No two people have the exact same response to injuries or to treatments. For this reason, the guidelines recommend that chronic low back pain sufferers who do not respond to the above treatments try medications like NSAIDs (nonsteroidal anti-inflammatory drugs) or muscle relaxants.


Unfortunately, despite the fact that there is very little evidence to support its use in non-cancer-related pain, opioids are still commonly prescribed for managing low back pain. In 2017 a study found that almost 15% of private insurance patients who saw their doctor for acute low back pain were given a prescription for an opioid. While this number is down from the almost 30% of patients in 2015, we still have some way to go in reducing the number of opioid prescriptions for low back pain, especially when we know that opioids are less than 30% effective for treating pain that isn’t related to cancer. Opioids should only be considered if other treatments have been unsuccessful and if the benefits outweigh the risks for that particular individual.



The NASS found that there was insufficient evidence to make recommendations either for, or against, TENS units or spinal cord injections.


Do Treatments Like Steroid Injections and Spinal Cord Stimulation Work For Low Back Pain?

The North American Spine Society evaluated all of the available clinical research on these topics and found that there was insufficient evidence to make recommendations either for, or against, these treatments.



Research shows that those who “use exercise to facilitate recovery” are “predicted to have better functional outcomes over time.

Resting Or Staying Active? What Works Best For Low Back Pain?


When it comes to the duration and intensity of low back pain, the functional outcomes and how quickly people return to work after a low back pain episode, the research indicates that “those who exercise more at baseline” and those who “use exercise to facilitate recovery” are “predicted to have better functional outcomes over time than patients who do not exercise or use bed rest to help with recovery”. The NASS recommends staying active as that will have better short-term outcomes than resting.



Most healthcare professionals and workgroups do not recommend using TENS or traction.


Do Treatments Like TENS (Transcutaneous Electrical Nerve Stimulation) And Traction Work For Low Back Pain?


When it comes to clinical evidence supporting the use of technologies like TENS and traction, there is conflicting research with some studies showing positive effects, while others show no benefit at all. Because of this, most healthcare professionals and workgroups do not recommend using these types of treatments or, like the NASS, take a neutral position, neither supporting or opposing these therapies.


Therapeutic options like cognitive behavioral therapy (CBT) can actually reduce low back pain.


Does Therapy Actually Work For Low Back Pain?


It may sound strange, but therapeutic options like cognitive behavioral therapy (CBT), psychotherapy and/or neuroscience education have been found to be an effective way of reducing low back pain. Using these therapies in combination with physical therapy has also been found to be highly effective when it comes to the long term treatment of low back pain. These therapies have also helped to reduce depression and anxiety in low back sufferers, improved the return-to-work rate, and improved functionality.

Healthcare professionals around the world agree that staying active and using nonpharmacological therapies as first line treatment for the management of chronic low back pain.

Conclusions


While there are many different groups around the world that have put together comprehensive guidelines for the management of low back pain, most of them agree on the major aspects of treatment. The NASS, the American College of Physicians (ACP), The American Physical Therapy Association (APTA), The National Institute For Health And Care Excellence (London), and others have all made their summaries of the clinical evidence around specific treatments and have shown their support for staying active and using nonpharmacological therapies as first line treatment for the management of chronic low back pain.

We hope that this summary helps to answer some of your main questions around the many types of treatments available for low back pain, and helps you learn more about what really works and what is mostly myth. For more information on international guidelines see our article on “International Guidelines For Low Back Pain”.