New guidelines on lower back pain from a therapist’s point of view
Monday, February 20, 2017
Last week, the American College of Physicians (ACP) updated its guidelines on the treatment of patients with "non-specific lower back pain."
A review study was published online in The Annals of Internal Medicine that looked at research carried out up until November 2016 and included only randomized, controlled trials and systematic reviews. Research from all types of clinicians and including patients with acute, sub-acute and chronic lower back pain (LBP) was included in the search.
The findings led the ACP to promote the use of therapeutic aids and stress reduction techniques, more so than the prescription of painkilling and anti-inflammatory medications.
According to the guidelines, the first line of attack in acute cases should include heat therapies, acupuncture, and massage. More persistent cases should target the use of the above treatments, plus rehabilitative exercise and stress reduction techniques (specifically mindfulness training), or activities such as yoga and Tai Chi. Spinal manipulations are also recommended.
For those where pain persists on a long-term basis without help from these treatments, the ACP advises that medication prescribed should initially be NSAIDs, which if unhelpful could be replaced by tramadol or duloxetine. Opioids should be avoided where possible due to the risk of overdose or addiction.
The Alternatives to Medication
Whilst the ACP is recommending the use of alternative therapies, it also admits that the evidence demonstrating the efficacy of these treatment isn’t ideal. It describes them as, at best, "medium quality" (heat, exercise, mindfulness exercises and acupuncture in chronic cases) and, at worst, "low quality" (massage, acupuncture for acute cases, spinal manipulations, etc.).
This lack of solid, high-quality evidence does not necessarily mean a lack of efficacy, but just a difficulty in structuring and producing high-quality research studies.
A high-quality study should be double-blinded and randomized with a high number of participants, but in the case of these kinds of treatments, this is very hard to achieve. There is, after all, plenty of anecdotal and case study successes that demonstrate how effective treatments such as massage and exercise rehabilitation can be.
Stress Relief for LBP
Stress and depression play their part in pain, and this is well-accepted — hence the ACP’s recommendations for stress-reduction techniques. The Anxiety and Depression Association of America states on its website, "Back pain is more common in people with anxiety and mood disorders than those without them."
On the same theme, professor Roger Chou from the Oregon Health and Science University (author of a review study that the ACP used to define its new guidelines) agrees:
"In two people with the same MRI results, someone who is under high stress is more likely to experience increased pain levels over someone with lower stress levels."
What do the New Guidelines Mean for Physical Therapists?
Nothing! I don’t think these new guidelines will surprise many PTs or change the way they treat their patients. Getting people off long-term medications has always been a target for those in the rehabilitation field, so this adds nothing new.
But what the new guidelines may do is increase the number of referrals coming through to us from family doctors who would otherwise have recommended "rest and pain-killers."
One Size Doesn't Fit All
Difficulty in advising people on which treatment will be most successful (and any subsequent lack of treatment success) is largely due to the fact that there is no one-size-fits-all treatment. This is where many primary care solutions fail and a patient can fall (or be pushed) into a long-term pharmaceutical solution.
There are so many contributing factors to back pain, from mechanical elements such as posture, movement patterns and activity levels to genetic causes, past injury considerations and psychosocial aspects. In order to successfully treat a non-specific LBP patient, a thorough assessment of all of these factors is essential. Only then can the appropriate treatment be planned.
As LBP is such a complex animal with many components contributing to its development, why should we expect just one treatment to be effective?
We need to be addressing the mechanical factors with exercise rehabilitation, soft tissue treatment and spinal manipulation where appropriate. Alongside this, the psychosocial aspects should be tackled with relaxation, stress relief therapies, and through addressing of conditions such as depression and mood disorders.
In conjunction, we need to be looking at patients' daily lives to determine changes that may need to be made. These include looking at workstation setups and lifting techniques. Amendments to faulty movement techniques may be necessary for those where repetitive actions are unavoidable.
In summary, the avoidance of pharmacological dependence is not a new concept in the world of physical therapy.
The new guidelines are, however, a good thing to cement this thinking throughout the rest of the medical world. Lower back pain is a complex condition which should be assessed in all potential elements in order to formulate a comprehensive and well-rounded treatment plan.
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