Experts Issue Guidelines on Treating Low Back Pain

(HealthDay News) -- Primary care doctors shouldn't routinely order MRIs, CT scans and other diagnostic tests for patients with nonspecific low back pain, according to new joint guidelines released by the American College of Physicians and the American Pain Society.

The guidelines, which are published in the Oct. 2 issue of the journal Annals of Internal Medicine, include a method to guide primary care doctors and other clinicians in gathering and interpreting information during a patient's first visit. This formula would place them in one of three general categories:

• Nonspecific low back pain, which affects about 85 percent of patients.
• Back pain potentially associated with spinal conditions, such as spinal stenosis, sciatica, or vertebral compression fracture.
• Back pain potentially associated with another specific cause, such as cancer.

According to the new guidelines, doctors should not routinely order imaging or other diagnostic tests such as MRIs, CAT scans, or X-rays for patients with nonspecific low back pain. Such tests should be reserved for patients with severe or progressive neurological deficits or suspected underlying conditions such as infection or cancer.

The panel of experts who developed the guidelines also reviewed evidence on drug therapies and non-drug treatments for acute and chronic low back pain.

"Almost all medications reviewed had some benefits, but they have risks," guidelines co-author Roger Chou, head of the American Pain Society Clinical Practice Guidelines Program, said in a prepared statement. "Acetaminophen, for example, is very safe but might not be effective. NSAIDs have gastrointestinal and cardiovascular risks. Opioids and muscle relaxers can provide relief for those with severe pain, but their potential benefits and risks should be weighed carefully."

"Patients who prefer not to take medication can benefit from non-drug treatments, such as acupuncture, spinal manipulations and massage therapy. None, however, are proven to be more effective than others to warrant recommendation as first-line therapy," Chou said.

Lumbar supports help prevent recurrent low back pain

(Reuters Health) - Home care workers may experience fewer bouts of low back pain if they use lumbar supports, according to the first study to evaluate the devices in this setting.

"Low back pain is a major problem among home care workers," Dr. Pepijn D.D.M. Roelofs of Erasmus Medical Center in Rotterdam, the Netherlands, who was involved in the study, told Reuters Health. The current study suggests that for home care workers who suffer from recurrent low back pain, the addition of lumbar supports to a short course on healthy work habits may curb episodes of low back pain.

While workers frequently use lumbar supports to prevent low back pain, there has been very little research on the effectiveness of the supports.
Roelofs and colleagues had 360 home care workers, whose jobs included housekeeping or helping with personal care in people's homes, take a course on healthy work habits. Half were also assigned to the lumbar support group, and were told to use the supports on the days when they expected they might experience pain. Study participants chose from four different adjustable elastic supports widely available in the US and Europe.

After a year, the researchers found, people who used the supports had about 53 fewer days of low back pain than those who did not use back supports. There was no difference between the groups in the amount of sick leave taken. This may have been because sick leave time was high, and a larger study sample would have been necessary to identify any difference, Roelofs said; it's also possible that low back pain isn't an important contributor to sick leave time.
More research is needed to see why some workers use the devices and others don't, and to understand how lumbar supports actually work to prevent pain, Roelofs and colleagues say.

"Nevertheless, low back pain remains a major problem in industrialized countries, and lumbar supports may be a valuable addition to secondary prevention in the workplace," they conclude.

NSAID Drug Therapy Fails to Ease Back Pain

(HealthDay News) -- Two widely used treatments for acute low back pain -- nonsteroidal anti-inflammatory drugs (NSAIDs) and spinal manipulation -- did not help patients in a carefully controlled study, Australian researchers report.

That's not especially surprising, American specialists said, because the evidence for their effectiveness has never been overwhelming. In fact, new recommendations for treating lower back pain take the lack of effectiveness of these treatments into account.
However, this is one of very few studies to provide solid documentation of what happens -- or doesn't -- with the treatments, the experts said.

"They just don't work better than placebo control," said Dr. Todd J. Albert, professor of orthopedic surgery and neurosurgery at Jefferson Medical College, who was not involved in the research. "But they are two common things that physicians do all the time. Patients come to a hospital feeling entitled to a treatment, and doctors feel they have to treat," he said.

The Australian study, done at the University of Sydney, included 240 people who had been treated with acetaminophen for low back pain without getting major relief. They were divided into four groups -- one getting the NSAID diclofenac (sold as Voltaren) at 100 milligrams per day and manipulative therapy, another getting the drug and a fake manipulative therapy, a third getting real manipulative therapy and a placebo drug, and the fourth getting a placebo drug and the fake manipulative therapy.

"Neither diclofenac nor spinal manipulative therapy gave clinically useful effects on the primary outcome of time to recovery," the researchers report in the Nov. 10 issue of The Lancet.
New guidelines just issued by the American College of Physicians and the American Pain Society already advise against general use of the two therapies, noted Dr. Daniel Mazanec, associate director of the Cleveland Clinic Center for Spinal Health.

"For this group of patients, with acute nonspecific low back pain with an average duration of nine days, the guidelines recommend the importance of staying active and [taking] relatively simple painkillers such as acetaminophen," Mazanec said.
Still, "this is the first study in a well-characterized group of patients to support the guidelines," he said.

The potential side effects of NSAIDs make avoiding them advisable if possible, Albert said. But one or another of them may still be used in individual cases, since different people may get some relief from one NSAID but not another, he said.

"There is individuality to response," he said.
Other NSAIDs include aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve).

While diclofenac did not speed the progression to recovery from pain, "that doesn't mean it should not be used, because it may make patients more comfortable along the way," Albert said.
Side effects of NSAID treatment in the study included gastrointestinal disturbances, dizziness and heart palpitations. However, the incidence of such side effects was about the same in the group getting the placebo drug treatment, the researchers noted.

Physical examinations for back pain

For about four out of five people walking into their doctors' offices with low back pain, the cause is unknown. That is, four times out of five the cause of low back pain is deemed "nonspecific." The doctor isn't able to identify a cause of back pain based on:

• What the person tells him or her
• A physical examination

In most cases of back pain, if you have no history of prior cancer or systemic disease and no apparent nerve problems, your doctor may not recommend diagnostic tests. Instead he or she may suggest an initial conservative approach to treatment. That's because the reason for your back pain is likely some sort of nonspecific musculoskeletal cause that may respond well to conservative treatment.

To rule out other causes of back pain, or to confirm a possible cause, your doctor may recommend one or more diagnostic tests. They may include:

• X-rays. X-rays can reveal bone problems, tumors or degenerative changes (wear and tear, or aging) in your spine.
• Computerized tomography (CT). Using computers and X-rays, CT scanners produce a series of images that can define disk and bone problems.
• Myelography. This test involves the injection of a special dye into your spinal canal. After the injection, X-rays of your spine can reveal a herniated disk or other lesions.
• Magnetic resonance imaging (MRI). This test combines a strong magnetic force with radio waves. The result is computer-generated images of bones, muscles, cartilage, ligaments, tendons and blood vessels. MRI testing can identify herniated disks or other problems with your back.
• Electrical nerve conduction test (electromyography, or EMG). This diagnostic approach measures the electrical impulses produced by nerves as they connect from your spinal cord, through your spine and on down to your muscles. Studies of your nerve pathways can confirm nerve injury caused by herniated disks or spinal stenosis.
• Bone scan. During a bone scan, a radiologist injects a radioactive substance (tracer) into one of your veins. Doctors then use a special scanner to locate bone tumors or compression fractures caused by osteoporosis

Chronic nonspecific back pain

Chronic nonspecific back pain is a common problem, and a sore back is one of the most common reasons that people in the United States seek medical treatment. However, just how common is difficult to say.

Describing back pain a challenge
Part of the challenge in precisely describing the scope of back pain is that most people who go to the doctor complaining of back pain have few or no objective physical findings. Instead, doctors rely on people's description of pain, on their perception of their limitations, and on their recall of how often they have experienced pain and to what degree. And, you and everyone else differ in how you perceive pain and in your response to it.

Additionally, when there are physical findings such as from a bulging or herniated disk, its existence may have little to do with pain. Bulging disks are a common cause of back pain for people older than 50, but some people with bulging disks have back pain and many others don't. To complicate matters, some people with no signs of age-related physical degeneration on X-rays may have back pain. In other words, two people with apparently the same degree of — or lack of — physical degeneration may have totally different experiences with back pain.

All of this makes classifying back pain and its prevalence difficult.

A common complaint
Research indicates that in 2003, Americans with back symptoms made about 4.8 million visits to hospital outpatient departments or to hospital emergency departments. A 2004 study showed that about 7.4 million American adults made health care visits (to a hospital and other settings) for nonspecific back pain. Other studies have shown that the prevalence of low back pain is between 15 and 20 of every 100 American adults.

As troubling as back pain can be, it is a common fact of life. For most people, and for most of the time, improvement in chronic back pain occurs with self-care means or with conservative treatment. For most people with chronic low back pain, symptoms wax and wane over time, and they have strategies for dealing with them. See your doctor when your usual strategies for dealing with pain are no longer effective and the pain is worsening — particularly if the pain is affecting your work life or your life outside of work.

Back Pain

Your sore back is a nuisance, or worse. It may prevent you from doing what you need to do — for example, work — or what you want to do, such as enjoyable pastimes. You may have reached the point of wondering: "Will I be able to keep my mind off the nagging pain today? Will my back pain ever go away? When can I get better and become more active again?" If you're like millions of other Americans who deal with chronic nonspecific back pain, you're more than familiar with these questions.

Chronic nonspecific back pain is different from the occasional sore back you might have for a day or two after too much gardening or painting the ceiling. Unlike instances of acute back pain, chronic nonspecific back pain is:

• Long lasting. To be termed chronic, back pain usually has been present for three months at a time
• Recurring. Even after resolution of one long episode of back pain, pain tends to return. However, the recurrence is highly variable among people and unpredictable.

Chronic nonspecific back pain is the kind of back pain that, by definition, is "nonspecific." In other words, in most cases the cause is unknown or difficult to pin down. If this kind of back pain describes your pain, then this decision guide is for you. If you need information about back pain that's associated with a herniated disk, especially back pain that involves radiating leg pain or leg muscle weakness, see this guide's "Related links" section for a link to another guide dedicated to that topic.

Think of you and your doctor as partners in managing and treating your chronic back pain. You'll want to carefully consider all your options and the risks and benefits of each in relation to your lifestyle and what's important to you. The information in this decision guide is intended to help you understand the various treatment options, from more conservative to more invasive techniques, and help you decide which treatment — or combination of treatments — is best for you.

You'll read about people who made different treatment choices, and watch a Mayo Clinic specialist in physical medicine and rehabilitation answer frequently asked questions about back pain. This guide also frames key questions to help you in this important decision-making process.

Take about an hour to go through this information in sequence by following the links at the right or at the bottom of each page. This provides proper context and helps you understand more about chronic back pain, your treatment options, why other people made the choices they did, and the pros and cons to consider in making your decision.