Treating chronic low back pain: What does the current evidence say?

Introduction

Chronic low back pain lingers in the space between the ribs and the hips. It stays there, dull and steady, for more than three months, with no clear cause to name. It’s a burden felt around the world, a heavy weight that keeps people from living as they once did. By 2015, it had robbed the world of sixty million years of able life, a stark rise of over half since 1990 [1]. A broad array of primary care treatments are given to adults with low back pain. They range from drugs to therapies that need no medication. Patients are often told to keep moving. Exercise is prescribed. There is spinal manipulation and cognitive behavioral therapy. Each can stand alone or be used together in multimodal care [2]. This blog post aims to give a short, clear summary of the evidence on how well primary care treatments work for adults with non-specific chronic low back pain.

Pain Medication

Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed more than any other medicine around the world. They're often used for treating low-back pain. A systematic review of 65 studies, covering more than 11,000 patients, compared NSAIDs with placebo, other drugs, and other therapies [3]. The studies varied in quality. They showed NSAIDs give some short-term relief for people with acute and chronic low-back pain, as long as it doesn’t include sciatica. Sciatica brings pain and tingling down the leg. But for those with acute sciatica, there was no difference between NSAIDs and a placebo. In other words, the drugs had no more effect than a sugar pill. The review also showed NSAIDs work no better than other drugs like paracetamol, narcotic painkillers, and muscle relaxants. Placebos and paracetamol had fewer side effects than NSAIDs, though NSAIDs caused fewer problems than muscle relaxants or narcotics. The newer COX-2 NSAIDs don't seem to outperform the old ones, but they cause fewer side effects, especially fewer stomach ulcers. Yet, some studies included in the review point out that certain COX-2 NSAIDs carry a higher risk of heart problems.

Most management guidelines advise using simple painkillers like NSAIDs for low back pain. Yet, many people with low back pain are given opioids instead. In the United States, more than half of those on regular opioid prescriptions suffer from chronic low back pain [4]. In Australia, the three drugs most often given for back pain are opioids or a mix of opioids. Oxycodone makes up 11.7%, tramadol covers 8.2%, and the combination of paracetamol with codeine takes 12.1%. Together, these drugs account for a large share of all prescriptions written to ease back pain [5,6]. Yet, a systematic review and meta-analysis found that for those with chronic low back pain who can handle the drugs, opioid painkillers offer some short-term relief. But it’s little more than that [7]. The benefit doesn’t seem to matter much at the doses doctors recommend. There's no proof they work in the long run. As for acute low back pain, no one really knows if opioids help at all.

Manipulation and Mobilisation

A systematic review looked at patients with sudden low back pain [8]. It found that spinal manipulation brought slight relief in pain and function for up to six weeks. But the studies included for analysis varied greatly in their findings. The review did not say if manipulation or mobilisation helped with long-term back pain. Many studies have looked at manual therapies, like spinal manipulation and mobilization, for back and neck pain [9-12]. Earlier findings didn’t show much proof that spinal manipulation worked better than other treatments for chronic low back pain [13,14]. Yet, more recent reviews argue that spinal manipulation and mobilisation are valid choices for pain relief. The success of these treatments, though, can depend on how long the symptoms have lasted, how the therapy is given — whether it includes exercises, general care from a doctor, and at what dosage, or for how long. It also matters what the treatment is compared against and which outcomes are measured. These differences might seem like mixed results, but the bulk of the evidence points to manipulation and mobilisation as effective therapies when compared to other methods.

Some educators don’t like manipulation and mobilisation therapies. They point to an assumed risk of injury that comes with these treatments as the reason to avoid them. However, a review of 51 randomised controlled trials compared these therapies to sham (pretend) treatments, no treatment, other active methods, and mixed approaches. It found few adverse events [15]. An adverse event means death, a life-threatening event, hospitalisation, a longer stay in the hospital, or lasting disability. In 25 single-mode treatment studies, five reported no adverse events. Two saw minor events, mostly worsening symptoms. One study showed 2% of patients had serious issues, but these weren't tied to the treatment. The control groups showed no major difference in adverse events. 17 studies didn’t say anything about adverse events. In the multimodal studies, none reported serious adverse events. Ten didn’t mention adverse events at all, while ten said none occurred. Six studies saw mild issues, like soreness, fatigue, or a worsening of symptoms. In studies that did report adverse events, the authors didn’t explain what made an event “adverse,” how the data were gathered, or how often they checked in with patients. It seems the patients likely reported these events on their own, without much prompting.

Traction

For thousands of years, people have used traction to treat low back pain. Traction pulls two bones apart, making more room in the joint. There are different kinds of traction. Sometimes it's used with other treatments. The most common types are mechanical traction, where a motor pulls the bones, and manual traction, where the therapist uses their own weight to do the pulling. A systematic review looked at 32 studies involving 2,762 patients with all kinds of low back pain — acute, subacute, and chronic [16]. It found that traction, alone or with physical therapy, wasn’t better than sham treatments, physical therapy without traction, or other methods like exercise, laser, ultrasound, or corsets. This was true for people with or without sciatica. The type of traction didn’t make a difference.

Motor Control Exercise

Motor control exercise is a way of teaching the body how to move again, how the brain and muscles talk to each other to get things done. It's about retraining the brain to fire the right muscles at the right moment. When you’ve been hurt, or when pain grips you, the body forgets how to move as it once did. This kind of work is often part of physical therapy. It helps people find their balance, move the way they should, and ease their pain. It’s used for bad backs, weak joints, and other injuries. Still, a systematic review of 32 studies with over 2,600 patients showed little difference between motor control exercise and things like spinal manipulation or other types of exercise [17]. The evidence was weak, but it suggested that adding motor control to regular treatment didn’t make much of a difference. For those dealing with back pain that comes and goes, it seems motor control exercises and standard care might reduce the chances of pain returning, but the proof wasn’t strong. For those with chronic low back pain, the exercise seemed to help a bit more. It could ease pain better than doing nothing at all, though when compared to other therapies or exercise routines, the differences were small. Whether it was manual therapy, different exercises, or even electrical treatments, motor control exercise didn’t stand out much. It might be more useful than doing very little, but it doesn’t seem to make a big difference in improving the body’s ability to function. In other words, in both new and long-standing back pain, motor control exercise is no better than other treatments. It could lessen pain, but it didn’t do much for movement or disability.

Behavioural Treatments

Research shows that social roles and the mind play a part in the journey of chronic low back pain. Because of this, behavioural approaches like cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are now used to manage it. A review of 30 studies, with 3,438 people involved, examined the effectiveness of three therapies [18]. First, operant conditioning, which notes how external factors tied to pain can make it worse. Second, CBT, which tackles thoughts, feelings, and beliefs that set off the pain. Third, respondent therapy, which uses progressive relaxation or muscle feedback to ease muscle tension. The evidence, though moderate in quality, showed operant conditioning worked better than doing nothing in the short-term. There was little to no difference between operant conditioning, CBT, or a mix of therapies in the short or intermediate term. CBT, however, was better than standard care, which normally includes physical therapy, back education, and medical treatments in the short term. In the long run, there wasn’t much difference between behavioural treatment and group exercise when it came to pain relief or lowering depression. Adding behavioural therapy to inpatient rehab didn’t seem to improve the results of rehab alone.

Stretching

Since this platform looks at research on training for flexibility, what about stretching? It's something people often turn to right off the bat for easing back pain. The data show that stretching does help with chronic low back pain. It reduces pain and helps people move better. But how well it works can change depending on what you compare it to. Things like core stability exercises and Pilates come to mind. Both stretching and core exercises do the job of easing pain and improving movement in those with chronic back issues. But there's no clear proof that one is better than the other, at least not in the short term. Some studies lean toward core exercises being a bit more useful, thanks to how they work the deeper muscles in the core, but that advantage is small, and more research is needed [19,20]. Slump stretching, for example, has shown real promise for reducing pain and improving function quickly. It also helps with a wider range of movement in certain motions [21]. Regular stretching works, too, for pain and function. Still, it might not be quite as effective as things like Pilates, resistance training, or exercises that focus on the core [22-24]. Overall, the research points to a fifty-fifty split in stretching's effectiveness for back pain.

Summary

The evidence to favour one treatment over another for adults with non-specific low back pain is thin. More solid, high-quality reviews and trials are needed. These studies should focus on how well treatments work in real-life practice. They should take a hard look at NSAIDs, opioids, spinal manipulation, and behavioral therapies. Previous reviews hint that these might help in some cases. But we don’t know for sure. Future research must show us the way. Only then will we know what truly works for adults suffering from low back pain.

References

1] Hartvigsen, J. et al. (2018) 'What low back pain is and why we need to pay attention.' The Lancet, volume 391, number 10137, pages 2356-2367.

2] Foster, N. et al. (2018) 'Prevention and treatment of low back pain: evidence, challenges, and promising directions.' The Lancet, volume 391, voice 10137, pages 2368-2383.

3] Roelofs, P. et al. (2008) 'Non-steroidal anti-inflammatory drugs for low back pain.' Cochrane Database of Systematic Reviews.

4] Hudson, T. et al. (2008) 'Epidemiology of regular prescribed opioid use: results from a national, population-based survey.' Journal of Pain Symptom Management, volume 36, number 3, pages 280-288.

5] Australian Institute of Health and Welfare (AIHW) Medications prescribed for back pain (2009).

6] Williams, C. et al. (2010) 'Low back pain and best practice care: A survey of general practice physicians.' Archives of Internal Medicine, volume 170, number 3, pages 271-277.

7] Abdel Shaheed, C. et al. (2016) 'Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: A systematic review and meta-analysis.' JAMA Internal Medicine, volume 176, number 7, pages 958-968.

8] Paige, N. et al. (2017) 'Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: Systematic review and meta-analysis.' JAMA, volume 317, pages 1451-1460.

9] Bronfort, G. et al. (2004) 'Efficacy of spinal manipulation and mobilisation for low back pain and neck pain: A systematic review and best evidence synthesis.' Spine Journal, volume 4, pages 335-356.

10] Gross, A. et al. (2010) 'Manipulation or mobilisation for neck pain: A Cochrane Review.' Manual Therapy, volume 15, pages 315-333.

11] Schroeder, J. et al. (2013) 'The outcomes of manipulation or mobilisation therapy compared with physical therapy or exercise for neck pain: A systematic review.' Evidence Based Spine Care Journal, volume 4, pages 30-41.

12] Furlan, A. et al. (2001) 'A critical review of reviews on the treatment of chronic low back pain.' Spine, volume 26, pages E155-E162.

13] Assendelft, W. et al. (2003) 'Spinal manipulative therapy for low back pain: A meta-analysis of effectiveness relative to other therapies.' Annals of Internal Medicine, volume 138, pages 871-881.

14] Shekelle, P. et al. (1992) 'Spinal manipulation for low-back pain.' Annals of Internal Medicine, volume 117, pages 590-598.

15] Coulter, I. et al. (2018) 'Manipulation and mobilisation for treating chronic low back pain: A systematic review and meta-analysis.' Spine Journal, volume 18, number 5, pages 866-879.

16] Wegner, I. et al. (2013) 'Traction for low-back pain with or without sciatica.' Cochrane Database of Systematic Reviews, volume 8, article CD003010.

17] Sarahiotto, B. et al. (2016) 'Motor control exercise for nonspecific low back pain: A Cochrane review.' Spine, volume 41, number 16, pages 1284-1295.

18] Henschke, N. et L. (2010) 'Behavioural treatment for chronic low-back pain.' Cochrane Database of Systematic Reviews, volume 7, article CD002014.

19] Nwodo, O. et al. (2021) 'Comparative effects of stretching exercises and core stability exercises in patients with chronic non-specific low back pain: A review of randomised clinical trials.' Nigerian Journal of Experimental and Clinical Biosciences, volume 9, 219-226.

20] Waqqash, E. (2014) 'Efficacy of core stability exercise and muscular stretching on chronic low-back pain.' Proceedings of the International Colloquium on Sports Science, Exercise, Engineering, and Technology.

21] Pourahmadi, M. et al. (2018). 'Effectiveness of slump stretching on low back pain: A systematic review and meta-analysis.' Pain Medicine, volume 20, pages 378–396.

22] Hayden, J. et al. (2005) 'Systematic review: Strategies for using exercise therapy to improve outcomes in chronic low back pain.' Annals of Internal Medicine, volume 142, pages 776-785.

23] Hayden, J. et al. (2005) 'Meta-analysis: Exercise therapy for nonspecific low back pain.' Annals of Internal Medicine, volume 142, pages 765-775.

24] Fernández-Rodríguez, R. et al. (2022) 'Best exercise options for reducing pain and disability in adults with chronic low back pain: Pilates, strength, core-based and mind-body. A network meta-analysis. 'The Journal of Orthopaedic and Sports Physical Therapy, volume 52, number 8, pages 505-521.