A Comprehensive, Evidence-Based Guide To the New Science of Treating Low Back Pain
Mainstream medicine has failed people with low back pain.
Low back pain is one of the top reasons people seek medical care in the US – it’s certainly the most common reason patients seek us out at Ascent Chiropractic – and it affects a whopping 29% of adult Americans. It’s also the leading reason for missing work anywhere in the world.
The US spends approximately $90 billion a year on back pain — about the same amount that it spends on cancer — and that doesn’t include the estimated $10 to $20 billion in annual lost productivity caused by back pain.
Medical professionals describe back pain in a few different ways, but the kind most (about 85%) suffer from is what’s called “nonspecific low back pain.” This means the pain has no pathological cause to pinpoint — like a tumor, fracture or infection.
Nonspecific back pain is the kind the mainstream medical community is usually terrible at treating. Many of the most popular treatments for chronic nonspecific low back pain — bed rest, spinal surgery, opioid painkillers, steroid injections — have been proven to be ineffective at best, and sometimes outright harmful.
Opioids Aren’t The Solution
In 2019, over 50,000 Americans died from opioid-related deaths, and it’s only getting worse. Opioid prescriptions are extremely common for those suffering from chronic back pain, with almost 20% of patients receiving long-term opioid prescriptions – codeine, fentanyl, hydrocodone, oxycodone or methadone.
Here’s the outrageous part: Most of these opioid prescriptions were being prescribed before we actually knew if they really helped those with chronic low back pain. The sobering truth? New studies are now showing opioids really aren’t all that effective for relieving low back pain.
A 2018 randomized controlled trial published in JAMA was the first to compare the long-term effectiveness of opioids versus non-opioid medications (such as ibuprofen or Tylenol) for chronic low back, hip and knee pain.
After a year of treatment, the researchers found opioids did not improve patients’ function any more than non-opioids. In fact, the patients on opioids were actually in slightly more pain compared to the non-opioid group (the result of something called “opioid-induced hyperalgesia” — increased pain sensitization brought on by these drugs).
Neither Is Surgery
As for surgery, only a small minority of patients with chronic low back pain actually require it. Specifically, patients with severe, progressive motor weakness, or symptoms of cauda equina syndrome (loss of bowel and/or bladder control) are candidates for surgical intervention. That’s according to UpToDate, a widely-used service that synthesizes the best available research for clinical decision-making.
Multiple clinical trials have shown there’s no clinically meaningful difference when comparing the long-term outcomes of patients who opt for spinal fusion (which has become more and more popular in the US over the years) with those who receive conservative, nonsurgical treatment like chiropractic and physical therapy treatment.
What About Corticosteroid Injections?
Over the past decade, corticosteroid injections for back pain have exploded in popularity, with over 9 million injections given every year for spinal pain! However, they tend to have similarly lackluster results: even if they improve pain in the short term, the effects dissipate within a few weeks or months, and they do nothing to address the root cause of the problem.
Corticosteroid injections have also been shown to increase the risk of a spinal fracture by 21% due to bone demineralization, accelerate patients’ osteoarthritis progression, and cause damage to tendons and soft tissues over time.
Why Does It Matter?
It’s not entirely surprising that surgeries, injections, and prescription drugs often fail considering what researchers are now learning about back pain. But despite the clear risks, doctors have continued to overprescribe painkillers and perform surgeries and steroid injections, often because patients won’t take no for an answer.
Enter Alternative & Complementary Therapies
Slowly, though, the tide is shifting.
Medical societies and public health agencies – including the National Institutes of Health, the National Institute of Health and Care Excellence, Towards Optimized Practice, the Journal of Orthopedic and Sports Physical Therapy, and Harvard Medical School – are now advising doctors to try less invasive options like chiropractic manipulation and even alternative therapies such as acupuncture before considering opioids or surgery.
Most recently, the American College of Physicians advised doctors and patients try non-drug therapies such as chiropractic, exercise, and even acupuncture, tai chi or yoga for low back pain. They suggest avoiding opioids, fusion surgery, and injections whenever possible, because there’s now so much evidence of ineffectiveness and harmful side effects. On the other hand, the alternatives carry little or no risk of harm — which makes them all the more appealing amid the historic drug crisis. Only if non-drug therapies fail do they recommended nonsteroidal anti-inflammatory drugs, and tramadol or duloxetine as a last resort.
The CDC also came out with new guidelines in 2016 urging health care providers to turn to non-drug options and non-opioid painkillers before considering opioids.
So What Does Work?
One of the biggest paradigm shifts in mainstream medicine is that nonspecific low back pain should not been considered a homogenous condition; no two cases are identical. Fittingly, there’s no one-size-fits-all approach to treating low back pain.
However, there are some things the science agrees on.
Moving Is Essential For Back Pain
When back pain strikes your first instinct may be to avoid physical activity and retreat to your bed until it disappears. But experts agree that in most cases, this is probably the worst thing you can do. Studies comparing exercise to no exercise for low back pain are consistent: Physical activity can help relieve pain, while being inactive can delay a person’s recovery.
Exercise is helpful for a number of reasons:
- It can increase muscle strength, which can help support the spine.
- It can improve flexibility and range of motion in the back, which can help people’s functional movement.
- It can boost blood flow to the soft tissues in the back, which promotes healing and reduces stiffness.
Researchers in a 2016 review of the research on nonspecific low back pain summarized exercise’s range of benefits, including these pretty notable findings:
“Aerobic exercise for 20 min on a bicycle at 70% peak oxygen uptake reduced the pain perception for more than 30 min for patients with [chronic low back pain].”
“Improving the flexibility of the lumbar spine and hamstrings can significantly reduce [chronic low back pain] by 18.5%–58%.”
“Core stabilization programs have been shown to significantly reduce [chronic low back pain] by 39%–76.8%, and a muscular strength program significantly reduced [back pain] by 61.6%.”
The research suggests that a combination of exercises — strength training, aerobic exercise, and flexibility training — is the best approach, as each type of exercise has its own benefits. But any exercise is better than no exercise, so if you find something you enjoy, do it.
To be clear, exercise isn’t always recommended for short-lived acute episodes. But if you have chronic back pain, you’ll want to find ways to work through the discomfort and get active.
Six of the most popular, evidence-based, spine-safe workout programs I’ve developed for patients are available free for download here.
Yoga Seems To Help Back Pain
There’s a ton of research on back pain and yoga. Taken together, the evidence pretty uniformly suggests yoga can both decrease pain and improve back-related function. The most recent Cochrane review on yoga and chronic low back pain, published in 2017, sums up the results of the best available studies:
“There is evidence that yoga compared to non-exercise controls results in improvements in back-related function and pain at three and six months.”
An additional study from the Annals of Internal Medicine found that 3 months of daily yoga specifically targeted at relieving low back pain reduced the number of patients requiring pain medication by over 50%.
Here’s our guide to the 8 best yoga poses for relieving low back pain.
Where Does Physical Therapy Fit In?
So where does physical therapy — usually a combination of guided exercises, mobilization, soft tissue release techniques and superficial heat or cold — fit into the back pain treatment picture?
Based on the evidence, physical therapy by itself hasn’t been shown work better than simple advice to remain active when it comes to reducing pain and improving function. Perhaps not surprisingly, multidisciplinary therapy – that means physical therapy combined with other approaches like chiropractic treatment – works significantly better to relieve chronic back pain in both the short and long term. Patients who get both are also more likely to return to work faster.
Do Ultrasound, E-Stim, or Cold Laser Therapy Work?
There’s a whole family of “stim” therapies based on the hope that biology will work better if it’s energetically stimulated: by electricity, by laser light, by ultrasonic vibration, or by far infrared radiation. All are supported by scraps of vaguely promising evidence; but the reality is that none are actually proven effective for long-term relief of basically anything.
For example, ultrasound therapy has been one of the ‘Greatest Hits’ of musculoskeletal medicine since the 1950’s. There are two basic flavors of therapeutic ultrasound – the ordinary kind familiar to most people and its more expensive, intense, painful, and high-tech and over-hyped cousin, Extracorporeal Shock Wave Therapy (ESWT) – but both share the basic principle of “stimulating” tissue with sound waves above the range of human hearing.
Almost everyone seems to assume that ultrasound is proven — good technological medicine — but that just doesn’t seem to be the case.
Unfortunately — although there are some interesting exceptions for certain conditions like elbow tendonitis — ultrasound is not a promising therapy for most of the painful problems it is used for. Ultrasound, e-stim and cold laser are all treatments that are easy to test against placebo, and yet there are few such studies in the scientific literature, and most of them are seriously flawed. Conclusions from evidence reviews like this one published in the journal Pain are typical:
“As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. The large majority of 13 randomized placebo-controlled trials with adequate methods did not support the existence of clinically important or statistically significant differences in favor of ultrasound therapy.”
Although ultrasound, e-stim and cold laser are almost certainly useful for some patients for some conditions, some of the time, they aren’t reliable or evidence-based therapies, and enjoy far more credibility than they deserve.
The Evidence On Massage Therapy
In general, massage therapists work by manipulating the muscle and soft tissue of the back and body. There are many, many different styles of massage: Swedish, deep tissue, sport, myofascial release, Thai, the list goes on. Massages also vary in how long they last, how much pressure is used, and the frequency of sessions, which makes it difficult to come to concrete conclusions on its clinical effectiveness. The fact is, massage is as much as an art as it is a science.
But there’s good news here: Massage is extremely safe, and the researchers who study back pain say the approach makes sense from a pain relief perspective. According to both AHRQ and Cochrane, for subacute and chronic low back pain, massage seems to improve symptoms and function in the short term — but there’s no evidence that it leads to any long-term change.
Acupuncture Seems To Help – But It’s Controversial
One of the oldest approaches to back pain is acupuncture, a core part of traditional Chinese medicine.
A 2005 Cochrane review looked at the evidence for acupuncture and low back pain and came to a few useful conclusions: There was “insufficient evidence” to make any recommendations about acupuncture for acute low back pain — so it may or may not help people. For chronic pain, acupuncture seemed to offer more pain relief and improved function compared with no treatment or sham treatment. But they didn’t find it to be any more effective than other traditional treatments for back pain.
The authors of the Cochrane review later pointed to a more recent randomized trial, which came out in 2009 after their review was published: It also found that acupuncture seemed to reduce chronic low back pain — but noted that it didn’t seem to matter where the needles were placed, hence the controversy over the meridian/qi philosophy underpinning the practice.
Finally, How About Chiropractic?
Based on the latest research, chiropractic (by itself or combined with active physical therapy) might be your best – and most cost-effective – bet for low back pain relief.
A 2017 review published in the Journal of the American Medical Association found that, compared to other popular mainstream medical treatments, spinal manipulation may be your best choice for chronic low back pain.
That’s backed up by the Cochrane 2011 review on chronic low back pain that found that spinal manipulation appreciably reduced pain and improved patients’ functional status. UpToDate’s review on the randomized trials that have come out since the Cochrane review further support those conclusions, finding that spinal manipulation delivered notable benefits for chronic back pain sufferers.
Those with acute back pain (less than 4 weeks duration) or subacute back pain (between 4-12 weeks duration) fared even better in those studies. In a 2013 trial published in SPINE journal, over 73% of people with acute or subacute back pain who saw a chiropractor in addition to their medical doctor found significant or complete relief from their pain, compared with 17% in the standard-medical-care-only group.
Add to that the fact that the chiropractic care is by far more cost-effective than traditional medical care for back pain. According to data published in 2014 that looked at 3.7 million patients, those suffering from low back pain spent almost 500% more when they took the orthopedic route for treatment compared to those who saw a chiropractor first instead.
In fact, for most patients, the combined out-of-pocket cost for imaging, diagnosis, and a complete corrective treatment plan at Ascent Chiropractic is a fraction of the cost for just an MRI alone – which, by the way, have been shown to be mostly unnecessary when it comes to back pain.
Don’t get me wrong, the chiropractic profession has its problems, and blindly defending it minimizes legitimate concerns. There are still way too many chiropractors prescribing one-size-fits-all treatment plans, claiming they can treat conditions outside our scope of practice, failing to base their patient care on the best-available evidence, and adhering to unscientific ‘metaphysical’ concepts of health. But when it comes to treating back pain, the science shows that nothing beats manual spinal manipulative therapy – aka chiropractic adjustments.
One Thing Is Clear: We Need To Make Our Default Choices More Back-Friendly
There’s a pretty simple principle that public health officials are supposed to follow: Make it easy for people to stay healthy, and make it hard for them to get sick. Unfortunately, when it comes to back pain in America, we make it easy for people to get sick and hard for them to stay healthy.
There’s a disconnect between what insurance providers will cover for low back pain sufferers and what actually helps alleviate their pain. It’s still much easier to get opioids or back surgery paid for by your insurance provider than to get a chiropractic or exercise program reimbursed – and as more research shows what works and what doesn’t, we need to push for that to change.
The Ascent Chiropractic Difference
Suffering from low back pain, or have friends or family members that could benefit from what we do at Ascent Chiropractic? Looking at the excellent clinical track record of what we do, it’s an easy decision. To get started, make an appointment at Ascent Chiropractic in Brookfield by calling 262-345-4166 or schedule an appointment with our online scheduling app.