A March 2018 report from NBC News highlighted a series of research articles in the Lancet medical journal on low back pain. The bottom line: doctors are over-prescribing medications (especially opioids) and surgery, and rarely prescribing less invasive treatments that have evidence to support their use, such as physical therapy, massage therapy, stretching and psychological counseling. According to the authors, “the concern is that the prevalent health-care approaches for low back pain contribute to the overall burden and cost rather than reducing it.”
This isn’t exactly news. In 2016, the CDC issued new guidelines for opioid prescriptions for chronic and acute pain, emphasizing the danger of long-term use of opioids. The guidelines recommended that the first line of treatment for pain conditions should be non-pharmaceutical, including massage therapy and cognitive therapy. In 2017, the American College of Physicians issued guidelines for the treatment of low back pain that emphasized the use of non-pharmaceutical treatments, including massage therapy, acupuncture, spinal manipulation and superficial heat. Both sets of guidelines were developed to reduce the risk of opioid-based treatments, as well as to help patients resolve rather than mask their symptoms.
Low Back Pain: Top Cause of Disability
Low back pain is the top cause of disability world wide, and US doctors prescribed opioid painkillers for more than 60% of patients with low back pain, despite their limited positive effect and the danger of addiction or overdose. Despite guidelines that recommend against the routine use of imaging studies for low back pain, many doctors do order x-rays or MRIs routinely. Doctors that use imaging studies such as MRI scans on patients with low back pain may incorrectly identify a structural abnormality as the cause of the pain, resulting in unnecessary surgery and added expense, risk, and pain for the patient.
The cause of low back pain is difficult to identify in most cases. Physically demanding jobs, smoking, obesity, and chronic mental or physical conditions are factors that increase the odds of experiencing low back pain. A very small percentage of people with low back pain may have a condition such as vertebral fractures, arthritis, herniated discs, malignancy, or infection that requires a specific treatment. Those patients generally will have additional history or symptoms in addition to back pain.
The Lancet articles suggest that people with low back pain should seek medical treatment from a primary care physician rather than an emergency room. Treatment should promote participation in physical and social activities and prevent and minimize disability. The first line of treatment for an acute episode of back pain should be reassuring the patient that low back pain is typically not serious and will resolve, and encouraging the patient to avoid bed rest and continue regular activities. For recurrent low back pain, first line treatments should be non-invasive and safe, such as physical therapy, exercise (yoga can be as effective as physical therapy), massage therapy, and counseling. Since stress is often associated with low back pain, progressive relaxation and mindfulness-based stress reduction programs may be recommended. Opioid therapy is only recommended for short-term use in carefully selected patients, with appropriate monitoring.
The Take-Away
Low back pain is common, generally resolves on its own, and is rarely disabling. Frequently used medical practices such as recommending bed rest, imaging studies, opioid medications, injections, and surgeries are in most cases not necessary and in many cases detrimental to the health of the patient. Such practices should be reserved for a very small percentage of people who have low back pain with other symptoms. The most effective treatment of low back pain is also the least dangerous and least costly: exercise, manual therapies (such as massage), and stress-reduction programs.
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