Clinicians should increasingly turn to noninvasive treatments for acute, sub acute and chronic low back pain, according to an updated practice guideline from the American College of Physicians.
The guideline, which appears in the February edition of the Annals of Internal Medicine, is the first update since the guideline was first proposed 10 years ago.
Over the last decade there have been many new studies and trials published that demonstrate the efficacy of non-pharmacologic, pharmacologic and pain interventional studies. With the increasing information clinicians are now more informed than before about the options but this can also lead to a mixture of “regimes” depending on who you ask.
Dr. Amir Qaseem, MD, PhD, vice president of clinical policy for the American College of Physicians stated that “We hope that physicians will look at our recommendations and provide evidence-based care to their patients. Talk to your patients, and tell them about the generally favorable prognosis of acute low back pain, regardless of the treatment. It is important that clinicians offer non-pharmacologic treatment before taking the pharmacologic route for acute, sub acute or chronic low back pain.”
For acute or sub acute pain lasting less than 12 weeks, the guideline recommends starting with a treatment option such as superficial heat, massage, acupuncture or spinal manipulation.
Dr. Dominic Hegarty (Clinical Director Pain Relief Ireland) supports the “shared-information approach”. In fact he believes talking to patients and giving them the options and the expected outcome is a “vital part of the treatment”. The ultimate goal is to keep individuals active and to resume normal duties / activity as soon as possible.
The final decision should be based on patient preferences, costs and availability of these non-pharmacologic interventions.”
The recent report underlines the fact that non-pharmacologic interventions “are quite effective in improving pain and function”. In addition, no serious adverse events have been reported for these interventions and they can be started immediately.
For chronic low back pain, non-pharmacologic interventions include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, cognitive-behavioral therapy or spinal manipulation are all proposed as options. Dr. Hegarty suggests that everything needs to be “tailored to the individual patient” and what is possible in some parts of the world may not be practical in others. In the future such things as “prescribed exercise plans” should be the norm.
What if non-pharmacological efforts fail?
The guideline states that if non-pharmacologic intervention proves futile, clinicians and patients should consider taking a pharmacologic route with non-steroidal anti-inflammatory drugs as a first-line option, or the opioid tramadol or the serotonin–norepinephrine reuptake inhibitor duloxetine.
All medicines have adverse effects and it is very difficult to predict how individual will response. The role of your doctor in suggesting what might suit each individual is vital
“It is important General Practitioners (GP) sit down with their patients and talk to them about the fact that taking a medication as the first step may not be best for them,” Dr. Hegarty says. “Instead, convey that the back pain will likely eventually start feeling better on its own.” Patients also should remain active and try non-pharmacologic treatments with the pharmacologic treatments to gain the best response.
What role do “opioids” have?
The role of “opioids” should be considered only for patients who have failed all other treatment options. Before dispensing, however, the physician needs to discuss with the patient the known risks of opioids and to be realistic about the benefits. Dr. Hegarty tries to avoid opioids as much as possible but “sometimes they are needed to gain control of the situation and should be reduced and eliminated as soon as possible”.
Is there a role for Pain Procedures?
There is a role for interventional procedures in the chronic / persistent phase and the timing of the intervention is important. “Using pain blocks/ injections in the early phase (in the first 12 weeks) are usually unhelpful and the outcome very mixed” in the opinion of Dr. Hegarty. When the lower back pain does not settle then the GP and patient should consider referring to a pain physician to explore the options.
Positive Welcome to the Guidelines
The guidelines are a welcome addition to the area of management. “This guideline is welcome. It is overdue,” said Natalia Morone, MD, associate professor of medicine at the University of Pittsburgh. “There have been a lot of studies since the original guideline was presented in 2007, particularly new evidence about using non-pharmacologic therapies for chronic low back pain.”
Dr. Morone applauds the guideline for avoiding the use of opioids, other than as a last resort for chronic back pain and never for acute back pain, because “there is no evidence that opioids provide any long-term effect.”
With any new guideline, “change can be a little slow to disseminate the findings widely and for clinicians to incorporate them,” Dr. Morone said. “I believe, however, that clinicians will try to implement the guideline because they want their patients to improve, particularly patients with chronic low back pain.”
However, the barrier for referring therapies such as acupuncture, mindfulness meditation, tai chi and yoga for chronic pain is that “they are not covered by most health insurance plans,” Dr. Morone said. Still, as time goes on, Dr. Morone believes that physicians will increasingly prescribe a menu of non-pharmacologic therapies for chronic back pain. “It is nice to have a wide variety of choices,” she said.