Back in March, the journal Lancet said of low back pain (Series from the Lancet Journals: Low Back Pain),
“Barriers to optimal evidence-based management include widespread misconceptions of the general public and health professionals about the causes and prognosis of low back pain and the effectiveness of different treatments, fragmented and outdated models of care, and the widespread use of ineffective and harmful care, particularly in countries regarded as models of high quality care.”
The authors are correct. The old model of low back pain management, including pain meds, anti-inflammatory drugs, muscle relaxers, corticosteriods, and even ANTIDEPRESSANTS — what I refer to as “THE BIG FIVE” — is, in their words, not mine, “sub-optimal, misconstrued, ineffective, fragmented, outdated, and harmful“. Stop and let these conclusions sink in for a moment.
While you can jump online and read this piece yourself, it’s not like they are the first GUIDELINES on low back pain. As you take a look at the examples below, recall our recent discussions on EVIDENCE-BASED MEDICINE, showing just how untrustworthy it really is (HERE and HERE) — a fact implied by the statement above. Below are some quips from previous guidelines.
- “In patients with low back pain, antidepressants and nonsteroidal anti-inflammatory drugs can decrease severity of pain. There is no clear evidence supporting the use of acupuncture, epidural steroid injections, muscle relaxants, spinal manipulation, transcutaneous electrical nerve stimulation, trigger point injections, heat therapy, and therapeutic ultrasound. Conservative treatment of adults with occupational nonspecific low back pain includes analgesic and anti-inflammatory medications, massage, and supervised and home exercise.” The November 2007 issue of Medscape (Recommendations Issued for Treatment of Nonspecific Low Back Pain) discussing recent guidelines from the journal, American Family Physician.
- “As defined by NICE in the Low Back Pain Guidelines published ‘Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain. Several structures in the back, including the joints, discs and connective tissues, may contribute to symptoms.’ In the past we did not have the capability of diagnosing low back pain and patients with low back pain were conveniently dumped into a group called ‘mechanical low back pain’ or ‘non specific low back pain’. In recent years there have been publications describing the neuroanatomy of the spine which has improved our understanding of the innervation of the different structures in the lower back which could be the source of pain. Simultaneously various techniques have been validated to precisely identify which structure in the lower back could be the source of patients pain thus providing the patient with an objective diagnosis and the possibility of logical, specific treatment. With the information we gather from clinical consultation, imaging studies and precision diagnostic techniques we can diagnose approximately 70% of low back pain.” From the June 2009 issue of the British Medical Journal (Practice Guidelines: Summary of NICE Guidelines: When is Low Back Pain Non-specific?)
- “The 2010 Global Burden of Disease Study estimated that low back pain is among the top 10 diseases and injuries that account for he highest number of DALYs worldwide. Low back pain is the leading cause of activity limitation and work absence throughout much of the world, imposing a high economic burden on individuals, families, communities, industry, and governments. Several studies have been performed in Europe to evaluate the social and economic impact of low back pain. In the United Kingdom, low back pain was identified as the most common cause of disability in young adults, with more than 100 million workdays lost per year. At present low back pain is treated mainly with analgesics. The causes of lower back pain are rarely addressed. Alternative treatments include physical therapy, rehabilitation and spinal manipulation. Disc surgery remains the last option when all other strategies have failed, but the outcomes are disappointing.” From the World Health Organization
- “Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Management guidelines endorse triage to identify the rare cases of low back pain that are caused by medically serious pathology, and so require diagnostic work-up or specialist referral, or both. Because non-specific low back pain does not have a known pathoanatomical cause, treatment focuses on reducing pain and its consequences. Management consists of education and reassurance, analgesic medicines, non-pharmacological therapies, and timely review. The clinical course of low back pain is often favorable, thus many patients require little if any formal medical care. Two treatment strategies are currently used, a stepped approach beginning with more simple care that is progressed if the patient does not respond, and the use of simple risk prediction methods to individualize the amount and type of care provided. The overuse of imaging, opioids, and surgery remains a widespread problem.” From the Lancet’s October 2016 issue (Non-Specific Low Back Pain)
What can we learn from these fragments? Only that there is no real consensus as to what works, not to mention the fact that figuring out which specific tissue is causing the pain is largely a pipe-dream. Nicole Mackee’s article for MJA Insight (Non-Specific Low Back Pain: Keeping it Simple) summed this up with her review of a recent article (Primary Care Management of Non-Specific Low Back Pain: Key Messages from Recent Clinical Guidelines) from the April issue of the Medical Journal of Australia.
“Experts have summarized key recommendations from guidelines recently released in the UK, Belgium, Denmark and the US. The guidelines have several new messages for clinicians, such as an emphasis on simple first-line care and early follow-up within 1–2 weeks. For patients who need second-line care, the researchers say that non-pharmacological treatments, such as physical and psychological therapies, should be tried before pharmacological options are considered. If drug therapy is used, it should be used at the lowest effective dose for the shortest time possible, the researchers advised. Surgical and interventional procedures have been found to be ineffective, they wrote. Messages from previous guidelines have also been reinforced in this latest advice, the researchers wrote. These include the avoidance of routine imaging, the use of a triage approach when classifying patients presenting with low back pain, and the use of advice, reassurance and self-management as the cornerstone in simple, first-line care. For patients with chronic non-specific low back pain, exercise and/or cognitive behavioral therapy has been recommended in the latest guidelines, the researchers reported.”
Allow me to make some observations as to where the guidelines and recommendations for NSLBP might be getting it right or may be missing the boat. Firstly, As I have shown you HERE and HERE, imaging — at least the most common forms of diagnostic imaging (X-ray, MRI, and CT) aren’t a fraction as helpful in making a diagnosis as the public has been led to believe — a fact verified by virtually every current study and guideline on low back pain (HERE is a form of imaging that might eventually prove far more helpful). Secondly, the new emphasis on CBT (Cognitive Behavioral Therapy) and “mindfulness,” while great for some people, is largely missing the boat as far as a most common cause of pain (HERE). In a similar vein, most people are not only aware of the OPIOID EPIDEMIC and the addictive dangers of this class of meds, they also know that back surgery is likewise a poor option (HERE). Third; listen to this statement from the March issue of Lancet we discussed earlier.
“Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, and it is increasing—disability due to back pain has risen by more than 50% since 1990. Low back pain is becoming more prevalent in low-income and middle-income countries (LMICs) much more rapidly than in high-income countries. Treatment varies widely around the world, from bed rest, mainly in LMICs, to surgery and the use of dangerous drugs such as opioids, usually in high-income countries.”
What grabs me here is not only that DRUGS and bed rest are still being used as a treatment for back pain (we know that there is a direct correlation between the length of time spent “bed-resting” and the potential permanency of a person’s back problem), but that we actually have to ask why third world countries are seeing a veritable explosion in low back pain. It’s a no-brainer folks. Although there are still plenty of countries being starved by their leaders (DPRK & VENEZUELA come immediately to mind), as increasingly large segments of the world come under the influence of Western culture, they become increasingly HEAVY and increasingly INFLAMED. And that, my friends, is the answer; when it comes to health problems and pain, inflammation is everything.
And fourthly, while I am a fan of physical therapy, remember that trying to have people stretch or exercise while they are MICROSCOPICALLY TETHERED by fibrosis / scar tissue not only is frequently not helpful, in many cases it makes people worse (HERE and HERE). The same sort of futility is seen with CHIROPRACTIC ADJUSTMENTS when given one after the next after the next after the next — particularly for non-disc problems (HERE).
So, while I feel that there are a myriad of things that will help people struggling with NSLBP, in most cases the primary cause of said pain is not being addressed in any logical or step-wise fashion. The first thing that must happen if you truly want to get at the underlying cause(s) of your back pain is that inflammation must be addressed. Not simply by prescribing another ANTI-INFLAMMATORY or CORTICOSTEROID, but by shutting it down at the source (HERE). Secondly, PROPRIOCEPTION and ranges of motion must be restored, while increasing CORE STRENGTH AND STABILITY. In other words, it’s important to realize that your back pain might be a symptom of a much bigger systemic problem (HERE).
Looking for a starting point? HERE is my post on effectively addressing back issues (specific or non-specific), which is actually not so different than my “UNIVERSAL CURE” post. If you are enjoying our work, be sure and like, share or follow on FACEBOOK as it’s a simple way to reach the people you love and care about most.