It shouldn’t be surprising, for a condition so common and with such pervasive consequences, that innumerable treatment modalities have been used to treat lower back pain. Some of these modalities have little or no scientific basis, such as the use of hologram bracelets, while others have substantial proof of efficacy.
As previously discussed, most cases of lower back pain are ‘mechanical’ lower back pain. As the vast majority of these cases can, and should, be treated conservatively, this discussion will focus on the non-surgical treatment modalities for lower back pain.
Firstly, and perhaps most importantly, there are a number of self-help strategies that have proven benefits for patients with chronic lower back pain.
– Remaining active has proven to be more effective than bed rest in both acute back pain (ie. less than 3 weeks) and subacute back pain (ie. 3 – 6 weeks). In addition, as an adjunct to exercise, remaining active has been shown to be the most effective strategy for improving pain and function in chronic lower back pain (ie. pain for longer than 6 weeks).
– Heat in various forms, including heated pillows and infrared lamps, have proven short term benefit in the management of acute lower back pain.
– The long term use of elasticised corsets, if worn correctly, can improve the symptoms of chronic lower back pain, and there is no evidence to suggest that this causes back muscle fatigue or weakness. On the other hand, there is insufficient evidence to recommend the use of a rigid lumbar support for mechanical lower back pain.
– A medium-firm, as opposed to a firm mattress, is proven to be better for patients with lower back pain. However, this doesn’t mean that bed rest is advised. In fact, bed rest for more than two to three days is ineffective and is probably harmful. Even when patients have sciatica (ie. symptoms in the leg from sciatic nerve irritation), the clinical outcome is the same whether they are bed-rested or remain active.
– Providing patients with the accurate, evidence-based information about their condition is a proven effective self-help strategy, on its own, in managing lower back pain.
There are a number of medications that can be used, with proven benefit, in the management of acute and chronic lower back pain. Your doctor will no-doubt prescribe the correct medicine for you, but there are some important considerations to bear in mind. Adequate pain relief can be achieved with oral painkillers, one should simply follow the World Health Organization’s ‘analgesic ladder’ when prescribing these medicines. Although muscle relaxants are often prescribed, the doses used by general practitioners are considered ineffective by the pain specialists. Most muscle relaxants are in fact unproven in managing lower back pain – also, they are all associated with adverse central nervous system effects and most have a significant side effect profile.
Some ‘older generation’ antidepressants have proven efficacy in the management of chronic lower back pain, although the newer agents are considered not as effective. It should be remembered that depression is often a comorbidity of most chronic pain conditions and should be managed on its own merits. Some anti-epileptic drugs are useful in back pain patients who have symptoms from nerve irritation. Lastly, systemic corticosteroids are no better than placebo for lower back pain, whether nerve irritation is present or not.
Spinal manipulation is of proven benefit in acute and chronic lower back pain, although it does not confer long term benefits. Interestingly, this treatment modality is of benefit independent of who does the manipulation (i.e. chiropractor or physiotherapist), as long as the practitioner is suitably trained. With regard to physiotherapy, there is surprisingly little research to prove the benefit of the different modalities, whether electrotherapeutic or manual, in changing the long term outcomes of lower back pain.
However physiotherapy remains an important adjunct in facilitating other treatment modalities (eg. exercise) and is important in getting the patient active. And there is no evidence that traction provides any benefit in lower back pain, whether nerve irritation is present or not.
And finally, what bout exercise? There is good evidence that exercise is not effective in acute lower back pain – in fact it can make the condition worse. Bear in mind, though, that ‘doing exercise’ is different to recommending that a back pain patient remains active within the limits of their symptoms. In contrast, exercise is perhaps the cornerstone of management of chronic lower back pain. This will be discussed in future articles.
Dr Mike Marshall