Back pain treatment – myths and reality

Most back pain cases resolve themselves within a month. At least, that’s what many believe.
And, like much of what we accept without investigation, it is wrong.
Turns out most back pain patients stop going to their doctor within a month – but their symptoms persist. Fully three-quarters of them still have symptoms a year after the initial onset of pain. This isn’t ‘new news’, in fact it was reported in the British Medical Journal a decade ago.
This wasn’t one of those “publish and forget” articles. The British have been focused on the diagnosis and treatment of back pain for years, and in subsequent years several studies analyzed different types of treatment, complicating factors, and the prevalence of back pain.
A 2003 study reported that although the condition may have been resolved within a few weeks, it looks like once you’ve had low back pain, there is a pretty good chance the symptoms will reappear. Seventy-three percent of patients will experience a recurrence, a figure essentially identical to that noted above.
One of the more interesting analyses indicated that rapid diagnosis and referral to a physiotherapist (PT) produced good results, as “More than 70% of patients required only a single [PT] clinic visit and <5% were referred on to specialist orthopaedic or back pain rehabilitation services." Another examined the tendency of some patients to ‘catastrophize’ their condition – exaggerate it and make it seem worse than it appeared from objective findings. Unsurprisingly, the results showed that a high level of pain catastrophizing or kinesiophobia (fear of movement) increased the individual’s risk of future chronic low back pain – and disability. This held true regardless of whether the study subjects had low back pain at baseline and still existed after correction for severity of back pain at baseline. The patients with those characteristics, who did not have pain at the time of the study were significantly more likely to experience pain.
So…what does work?
There is little evidence that invasive surgery produces better results (for most patients) than other forms of treatment.
From the BMJ:
“A number of interventions, including facet joint, epidural, trigger point, and sclerosant injections, have not clearly been shown to be effective. No sound evidence is available for the efficacy of spinal stenosis surgery. Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc prolapse that do not respond to initial conservative management. The role of fusion surgery for chronic low back pain is under debate. Recent randomised clinical trials comparing fusion surgery with conservative treatment showed conflicting results. Recommendations that fusion surgery should be applied in carefully selected patients are difficult to follow because no clear and validated criteria exist to identify these patients in advance.”
But there is evidence that more conservative treatments do produce results – the BMJ (again) :
“That exercise and intensive multidisciplinary pain treatment programmes are effective for chronic low back pain is supported by strong evidence. Some evidence supports the effectiveness of (cognitive) behaviour therapy, analgesics, antidepressants, nonsteroidal anti-inflammatory drugs, and back schools and spinal manipulation.”
Extensive citations are available here.
What does this mean for you?
I reported yesterday on the explosive growth of spinal surgery using implanted devices. Undoubtedly this type of care is highly beneficial – for some patients. What we don’t really know is which patients should be getting implants and who would be better off with conservative treatment.
Clearly, there is strong evidence that more patients would benefit from conservative treatment, leading one to suspect that the growth of invasive surgery is not driven by best practice.