New Thinking on the Treatment of Lower Back Pain
A new Show Me The Evidence article over on Vox is providing us with an interesting review of the changing conventional wisdom when it comes to treating back pain. At over 5,000 words, it’s going to be TL;DR for most people, so we thought we’d give a quick overview here just to give our readers a taste — but really, if you’ve got the time, do check out the original, which attempts to summarize more than 80 recent medical studies.
The Problem with Back Pain
According to the article, lower back pain affects nearly 30 percent of adult Americans and is one of the major reasons people seek help from their doctor. Approximately $90 billion is spent every year treating back pain in the U.S., with an estimated additional $10–$20 billion in lost productivity. And by far the most common diagnosis is “nonspecific low back pain” — persistent pain with no detectable cause. In cases where this pain becomes chronic, lasting 12 weeks or more, the most popular modern treatments recommended by doctors have been bed rest, spinal surgery, opioid painkillers, and steroid injections.
The Problem with the Treatments
Let’s just list them one by one:
- We’ve all heard about the troubles with opioids. Not only are we experiencing an epic of dangerous addictions to these drugs, but evidence is piling up that in the long run they do nothing to improve pain or function, and in fact can even make the pain worse.
- Only a small percentage of patients might benefit from surgery for nonspecific low back pain, with randomized trials showing no meaningful difference in outcomes between patients who get spinal fusion and those who get non-surgical treatment.
- Steroid injections have been shown to improve pain slightly in the short term, but the effects dissipate within a few months without improving long-term outcomes.
Is It All in the Mind?
Well, no, but the article points out an increasing awareness of the effect psychological and social factors play in the way each individual experiences pain. People under stress or prone to depression or anxiety tend to suffer more.
Medical societies and public health agencies are now advising doctors to try less invasive options before considering opioids or surgery. Alternatives that have been shown to bring moderate improvement are simple exercise, yoga, Pilates, Tai chi, and multidisciplinary “biopsychosocial” rehab. Even acupuncture showed potential.
Interestingly, the generic “physical therapy” option showed mixed results, not seeming to be any better than advice to “remain active.” However, the article points out that the wide variability in physiotherapy approaches makes it difficult to come to a clear conclusion on this.
The alternative that showed the most potential of all, however, was to find a “back whisperer” — a doctor of physical therapy with an orthopedic clinical specialist certification, a personal trainer with a degree in exercise science, a physical therapist — with special expertise in the spine.
The Trouble With the Alternatives
Although studies are showing these alternatives to be both more helpful and less risky than surgery or opioids, and the medical establishment is beginning to catch on, most medical insurance still lags behind, continuing to reimburse for the older, ineffective treatments but not yet willing to pay for other options.
“When it comes to back pain in America,” the article says, “we make it easy for people to get sick and hard for them to stay healthy.”