Treatment for low back pain

Ninety percent of acute low back pain attacks settle within six weeks, regardless of treatment.  Individuals may spend considerable amounts of money on private treatment that is not always necessary.  Bed rest should not be prescribed, although individuals may feel so acutely disabled they require bed rest; in these circumstances it should be limited to 3 days.  Analgesia and physical treatments are both useful and because of the short duration of symptoms, any intervention will have, or will be perceived as having, a good effect.  (Waddell, 2004). Military personel have similar outcomes, with 86% of Israeli Defence Force soldiers with acute low back pain returning to their job within six weeks (Eilat-Tsanani et al., 2010).

Treatment for non-specific back pain, with accompanying evidence, is comprehensively considered in the NICE Guidelines published in 2009 (Savigny et al., 2009).

Bed rest

Treatment should be holistic and multi-disciplinary with the expectation of gradual recovery with time. There is no evidence that bed rest is helpful, with good evidence that it delays recovery and can negatively effect long-term prognosis.

A Cochrane review found moderate quality evidence that patients with acute low back pain may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed. Patients with sciatica experienced little or no difference between the two approaches (Dahm et al., 2010).

Physical treatments

Physical treatment is in many cases unsuccessful because of the multimodal nature of the illness. 

There is some evidence that acupuncture can be beneficial, with no evidence to support use of TENS or lumbar supports. Recent studies of acupuncture have shown some beneficial effect in reducing pain and improving function and although not much difference between acupuncture and sham acupuncture was seen, overall there was felt to be a cost-benefit advantage.  There is no clear advantage from TENS or lumbar supports and these are not recommended for non-specific back pain.  Advice to stay active has small beneficial effects when used without other forms of treatment (Hilde et al., 2002).

Exercise programmes can speed recovery and prevent recurrences of back pain. A Cochrane review found moderate evidence that post-treatment exercise programmes can prevent recurrences of back pain, with a rate ratio of 0.50 (95%CI 0.34-0.73).  There was low quality evidence that the number of days off sick were reduced by post-treatment exercises (Choi et al., 2010).

There is no evidence that lumbar supports are of benefit. Lumbar supports may be advocated and are often used for low back pain.  There is evidence that shows they are no better than other forms of treatment for primary prevention, and no evidence that they are effective in secondary prevention.  The results may be affected by poor compliance overall in the various studies and more, better, studies are needed (Van Tulder et al., 2000).

Spinal manipulative therapy is often advocated, either through a physiotherapist, chiropractor or osteopath.  Studies of its use in acute or chronic low back pain have shown that it is no more effective than analgesia, other physical therapies, exercises or back school, and the profession of the manipulator did not affect outcomes (Assendelft et al., 2004).  It is not superior to other forms of treatment but may have a part to play in managing some individuals, particularly if they are known to respond well to this treatment.

Exercise is beneficial in reducing work disability. A systematic review and meta-analysis of randomised controlled trials found that exercise was more effective than usual care in reducing work disability in patients with non-acute non-specific low back pain in the long term, but no conclusions could be made about exercise types (Oesch et al., 2010).

Psychological treatments

Psychological rehabilitation particularly using treatment programmes such as cognitive behavioural therapy is effective (Flor et al., 1992)

Cognitive behavioural therapy is beneficial in the short term for pain and depressive symptoms. A Cochrane review of behavioural treatment for chronic low back pain concluded that there is moderate quality evidence that in the short term, operant therapy is more effective than waiting list (standardised mean difference -0.43, 95%CI -0.75 to -0.11) and behavioural therapy is more effective than usual care for pain relief (mean difference for short term pain relief -5.18, 95%CI -9.79 to -0.57). No specific type of behavioural therapy was more effective than another. In the intermediate to long-term there was little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. (Henschke et al., 2010)

Multidisciplinary treatments

There is moderate evidence that multidisciplinary rehabilitation is effective in treating sub-acute low back pain and a workplace visit and close liaison with occupational health providers increases effectiveness.  These interventions may not prove cost-effective and more research is needed (Karjalainen et al., 2003).

The use of 'work conditioning' programs has been shown to be effective in treating chronic back pain but not acute back pain (Schonstein et al., 2003).  These programs combine intensive physical training that includes aerobic capacity, muscle strength and endurance and coordination, in a process that is work related, with cognitive behavioural therapy.

A systematic review of guideline-endorsed treatments for low back pain found, for subacute and chronic low back pain, evidence supporting the cost-effectiveness of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy. No evidence was found to support medications, yoga or relaxation, and there were inconsistent results or lack of evidence for treatments for acute back pain (Lin et al., 2011).

Multi-disciplinary rehabilitation such as functional rehabilitation and pain management is also effective (Clinical Standards Advisory Group, 1994, Guzman et al., 2002), and there is moderate evidence suggesting that back schools in the occupational setting reduce pain and improve function and return-to-work status in the short and intermediate term, compared to exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls (Heymans et al., 2004).

Nerve root pain (radiculopathy, sciatica) treatments

The majority of individuals with nerve root pain, including those where disc prolapse is identified as the most likely cause, will recover in time and a complete resolution of symptoms is the expected outcome.

Surgery for nerve root pain speeds recovery but has no long-term advantages over conservative treatment. A comparison of 283 patients with severe sciatica for 6-12 weeks between early microdiscectomy, or conservative management with late microdiscectomy for those who required it, the probability of perceived recovery in both groups was 95%. There was a faster rate of perceived recovery in the early surgery group (Peul et al., 2007).

Non-surgical treatment is not particularly successful compared to just waiting for recovery.  There is no evidence that bed rest (Vroomen et al., 1999), advice to stay active without other forms of treatment (Hilde et al., 2002), traction (Werners et al., 1999), TENS, wearing a brace or corset, or manipulation (Koes et al., 1991) is more successful than placebo in treating nerve root pain.  Epidural steroids may produce short-term relief but no long term functional benefit (Watts and Silagy, 1995).

Few individuals should be permanently unfit for physically demanding roles such as the military, firefighting and police work, so any decision on permanent disability should only be made after all appropriate treatment options have been pursued, and you have specific advice to this effect from a specialist with expertise in spinal problems.

While back pain is unlikely to lead to permanent disability, significant pathology may affect future fitness for military service, police service and firefighting.  Lumbar disc prolapse is often cited as a significant problem, however in many cases it is asymptomatic, and in cases where discectomy is needed a full recovery is expected with a return to normal activity (Dollinger et al., 2008).  Few individuals fail to recover, and failure to recover is often linked to complex psychosocial issues.  More significant problems are associated with more complex spinal surgery, particularly decompression and fusion for conditions such as spinal stenosis, which may be complicated by disc prolapse. 

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