Lower Back Pain

Lower Back Pain

Andrew Buelt, MD, and Heidi James, MD

Andrew Buelt joins Heidi for a deep dive into the evidence for interventions for low back pain (LBP). Spoiler: don’t get your hopes up!

• General
  • 40% of people will experience LBP in their lifetime.
  • Most back pain improves with time.
  • Imaging is generally not helpful, especially in acute LBP.
    • Abnormalities noted on imaging are very likely to be incidental findings and not the cause of pain.
  • Published evidence on treatment of LBP is often contradictory.
• Acute LBP:
  • Acute LBP is that lasting <12 weeks.
  • American College of Physicians (ACP) recommends physical modalities of treatment: 
    • Treatment with superficial heat (moderate-quality evidence)
    • Massage, acupuncture, or spinal manipulation (low-quality evidence). 
  • A deep dive into the actual evidence shows the following:
    • Spinal manipulation doesn’t beat sham therapy at 1 month of follow-up.
    • Acupuncture shows a small improvement in pain with no improvement in function.
    • Massage doesn't beat sham massage at 5 weeks.
    • Superficial heat does give moderate improvement of 16-20 points on a 100-point scale but only for the first 3-4 days.
  • The ACP recommends the following medications:
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Muscle relaxants
  • The evidence supports using a moderate dose of an NSAID of choice and does not support routine muscle relaxant use.
• Chronic LBP:
  •  LBP lasting >12 weeks.
  • Exercise is the treatment of choice.
    • No particular exercise has shown superiority.
  • Spinal manipulation was helpful in suboptimally designed studies. 
  • The following lack evidence to recommend their use: ultrasound, transcutaneous electrical nerve stimulation (TENS), kinesiology, acupuncture, acetaminophen, systemic steroids, tricyclic antidepressants, and anti-seizure medications.
• Back pain with sciatica
  • Although anticonvulsants are frequently prescribed, literature does not support their use. 

PEARL: While it is discouraging that most of the treatments we recommend for LBP have not been proven beneficial, we can remind our patients that most back pain improves with time and that good ol’ NSAIDs for acute LBP and exercise for chronic LBP can be helpful.

REFERENCES:

A systematic review of the global prevalence of low back pain
Hoy D, Bain C, Williams G, et al. Arthritis Rheum. 2012;64(6):2028-2037. doi: 10.1002/art.34347. PMID: 22231424 

Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview
Oliveira CB, Maher CG, Pinto RZ, et al. Eur Spine J. 2018;27:2791-2803. doi: 10.1007/s00586-018-5673-2.

Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians
Qaseem A, Wilt TJ, McLean RM, et al. Ann Intern Med. 2017;166(7):514-530. doi: 10.7326/M16-2367. PMID: 28192789

The prognosis of acute and persistent low-back pain: a meta-analysis
da C Menezes Costa L, Maher CG, Hancock MJ, et al. CMAJ. 2012;184(11):E613-E624. doi: 10.1503/cmaj.111271. PMID: 22586331

Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain
Henschke N, Maher CG, Refshauge KM, et al. Arthritis Rheum. 2009;60(10):3072-3080. doi: 10.1002/art.24853. PMID: 19790051

Systematic literature review of imaging features of spinal degeneration in asymptomatic populations
Brinjikji W, Luetmer PH, Comstock B, et al. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi: 10.3174/ajnr.A4173. PMID: 25430861

Non-steroidal anti-inflammatory drugs for low back pain
Roelofs PD, Deyo RA, Koes BW, et al. Cochrane Database Syst Rev. 2008;(1):CD000396. doi: 10.1002/14651858.CD000396.pub3. PMID: 18253976

Comparison of oral ibuprofen at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial
Motov S, Masoudi A, Drapkin J, et al. Ann Emerg Med. 2019;74(4):530-537. doi: 10.1016/j.annemergmed.2019.05.037. PMID: 31383385

Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis
Cashin AG, Folly T, Bagg MK, et al. BMJ. 2021;374:n1446. doi: 10.1136/bmj.n1446BMJ. PMID: 34233900

PEER systematic review of randomized controlled trials: management of chronic low back pain in primary care
Kolber MR, Ton J, Thomas B, et al. Can Fam Physician. 2021;67(1):e20-e30. doi: 10.46747/cfp.6701e20. PMID: 33483410 

Trial of pregabalin for acute and chronic sciatica
Mathieson S, Maher CG, McLachlan AJ, et al. N Engl J Med. 2017;376(12):1111-1120. doi: 10.1056/NEJMoa1614292. PMID: 28328324

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