Pain in Primary Care

Low Back Pain: What Works? What Doesn't?

Charles P. Vega, MD


September 30, 2021

Dr Vega's Take

This one is easy. Choice 3, please.

You might remember that I advocated for acetaminophen despite its weak record of efficacy in the knee osteoarthritis case published on Medscape. However, in Henry's case, subacute back pain of 7 weeks' duration has made me abandon acetaminophen. In a systematic review by the American College of Physicians (ACP) published in 2017, acetaminophen was found to be no more effective than placebo for the treatment of low back pain. We have better treatment options.

I have been surprised by the number of patients with an acute low back strain, or even chronic low back pain, who receive treatment with systemic corticosteroids. The same review from ACP found that systemic corticosteroids are ineffective in the management of low back pain. But, worse than that, they may be harmful.

In a study of more 15 million adults between 20 and 64 years of age in a national health insurance database in Taiwan, 16.5% were found to have received a single course of corticosteroids. Patients had significantly higher risks for gastrointestinal bleeding, sepsis, and heart failure diagnoses in the 5- to 30-day period after receiving corticosteroids. Using a similar study design, these same authors demonstrated a higher risk for gastrointestinal bleeding, sepsis, and pneumonia among children and adolescents receiving short courses of corticosteroids.

What about getting some more information by ordering radiographs of Henry's lumbar spine? A randomized trial suggests that this is an ineffective strategy for the management of low back pain. Participants with low back pain who were randomly assigned to receive plain radiographs of the lumbar spine were more likely to report continued back pain at 3 months, and they had a lower overall health score. At 9 months, having had radiographs made no difference in health or functional outcomes. Finally, no serious spinal pathology was noted in either the radiograph or usual-care groups.

The ACP recommends against the routine use of diagnostic imaging for patients with low back pain, except in cases suspicious for serious pathology or a progressive neurologic deficit. They note that just 0.7% of cases of low back pain in primary care are due to metastatic cancer, whereas 0.01% and 0.04% of these patients have a spinal infection or the cauda equina syndrome, respectively.

This leaves us with physical therapy as the best option for the management of our patient, Henry. The value of exercise therapy over bed rest is clear; patients with low back pain should get moving and try to continue normal activities. However, no single form of exercise therapy — yoga, stretching, hydrotherapy, tai chi, or specialized back programs — has stood out as superior to others. Therefore, patient preferences and the availability of services locally are highly important. Exercise as simple as walking may be as effective as other nonpharmacologic interventions in low back pain for outcomes at 3 and 12 months.

My typical practice is to use analgesics for patients with subacute low back pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are recommended and usually provide modest efficacy in the relief of back pain. A multidisciplinary approach to care is most effective, including attention to psychosocial factors which may be promoting higher degrees of pain and disability.

Henry is trying a lumbar brace to help his pain and function at work, and it sounds like it has been at least somewhat successful. That is great, but the evidence on back supports is decidedly mixed. In two meta-analyses there was agreement that they do not appear effective in the prevention of back pain. There is heterogeneity in studies of lumbar supports for the treatment of back pain, with few high-quality studies. In the review by the Cochrane Library, the majority of randomized trials of patients with back pain failed to demonstrate a meaningful improvement with lumbar supports.

A more recent review found that lumbar supports were effective for pain and function, but it was published only as an abstract and does not offer any details. Overall, lumbar supports need better evidence from clinical studies before they can be recommended more broadly.

The combination of an exercise program along with simple analgesics should help this patient attain his goals of reduced pain with improved function, but of course there are other treatment modalities available as well. What has worked in your practice for subacute or chronic back pain? What is a waste of time or even potentially harmful? Please share your experiences in the comments section, and I look forward to reviewing them and adding my own commentary in the weeks ahead.


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