What works for chronic low back pain?

At present, no organisation has developed evidence-based guidelines for chronic low back pain. The evidence currently available indicates that established treatments either do not work or have limited efficacy. This article explores the three general categories for the treatment of chronic low back pain and the evidence available for these treatment options.

Chronic low back pain is defined as pain that has persisted for longer than 3months. It is associated with psychological distress, physical disability, time off work and depression. Whilst no evidence-based guidelines have yet been established for the management of chronic low back pain, the evidence is not lacking. In a clinical update published in this week’s edition of the “Medical Journal of Australia,” the current evidence-based practice points are discussed. The prevailing treatments for chronic low back pain fall into three broad categories: monotherapies, multidisciplinary therapy, and reductionism.MONOTHERAPIES can be defined as “interventions of a single, particular kind that a medical practitioner might prescribe as sole treatment.” Currently there is no evidence of the long-term efficacy for drug therapy with analgesics, NSAIDs, muscle relaxants or antidepressants for the treatment of chronic low back pain. In additon, opioids are only partially effective and do not improve function.Orthoses, transcutaneous electrical nerve stimulation (TENS), electromyographic biofeedback, traction, acupuncture, magnet therapy, injections into trigger points, and hydrotherapy are no more effective than sham treatment, placebo, or being put on a waiting list. Manipulative therapy has been found to be slightly more effective than sham therapy.For exacerbations of chronic low back pain, the evidence supports the use of willow bark and massage is emerging as an effective intervention that is commonly available.MULTIDISCIPLINARY THERAPY describes a biopsychosocial program involving combinations of exercises, education and behavioural therapy, with a prime focus being that of addressing physical disabilities and the patient’s interpretation of their pain.The current evidence suggests that multidisciplinary therapy based on intensive exercises improves physical function but has modest effects on pain. REDUCTIONISM decribes the “pursuit of a pathoanatomical diagnosis for chronic low back pain with the view to implementing a target-specific treatment.” This form of treatment does not take into account the psychosocial aspects of chronic pain and has been criticised for this reason. In most cases, the cause of chronic low back pain cannot be found using conventional investigations (i.e. radiography and MRI). However, evidence shows that diagnostic joint blocks and discography can provide a diagnosis in many cases. Using these techniques, it has been shown that between 15% and 40% of patients have zygapophysial joint pain, ~20% have sacroiliac joint pain and >40% have internal disc disruption. Target-specific treatment with radiofrequency can relieve zygapophysial joint pain and techniques are now emerging for treating sacroiliac joint pain and internal disc disruption. In conclusion, whilst no clear-cut management guidelines for chronic low back pain exist, prevailing and new therapies continue to be studied. The available evidence show that most established treatments either do no work or have limited efficacy, leaving the practicing physician with few options.(Source: Medical Journal of Australia 19 January 2004; Vol 180: pages 79-83)