Anyone with even a passing familiarity with worker's compensation is well aware of the statistics surrounding back pain and its impact on both employees and employers within the system. A new clinical guideline from the American College of Physicians (ACP) includes interesting new recommendations that reflect the seeming shift from aggressive care of back problems such as surgery to a more conservative approach, focusing on active movement as well as allowing adequate time for recovery. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians, American College of Physicians, Annals of Internal Medicine, 14 February 2017. (http://annals.org/aim/article/2603229/systemic-pharmacologic-therapies-low-back-pain-systematic-review-american-college)
The guideline opens with a reminder of sobering statistics: low back pain remains one of the most common reasons for physician visits in the U.S. with roughly one quarter of U.S. adults reported having low back pain lasting at least one day in a given three-month period. It also reiterates the high costs associated with back pain, both directly related to health care and costs to employers in missed work or diminished productivity. It cites these costs at $100 billion in 2006, of which two thirds were indirect costs of lost wages and productivity.
The guideline provides recommendations relating to the three clinical designations of back pain: acute, meaning pain that lasts less than 4 weeks; subacute, meaning pain lasting 4 to 12 weeks; and chronic, meaning pain that lasts more than 12 weeks. In evaluating treatment protocols, the ACP published three principal recommendations:
Recommendation 1 - Since most patients with acute or subacute low back pain improve over time regardless of treatment, physicians should provide treatment with superficial heat (moderate quality evidence), massage, acupuncture, or spinal manipulation (low quality evidence); if medication is provided, physicians should choose nonsteroidal anti-inflammatory drugs or muscle relaxants (moderate quality evidence). This was characterized by ACP as a strong recommendation.
Recommendation 2 - For patients with chronic low back pain, physicians should initially provide treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low quality evidence). This was also characterized by ACP as a strong recommendation.
Recommendation 3 - In patients with chronic low back pain who have had an insufficient response to non-medication treatment, physicians should consider treatment with nonsteroidal anti-inflammatory drugs as a first-line option, or tramadol or duloxetine as a fall back. Opioids should only be considered as an option in patients who have failed non-medication treatments and only if the potential benefits outweigh the risks for individual patients (moderate quality evidence). This was characterized by ACP as a weak recommendation.
In the aggregate, the recommendations are interesting, but are also rife with important qualifiers. As noted, the first two recommendations are characterized by the ACP as strong and the third one as weak. In ACP parlance, a strong recommendation means that there is certainty that the benefits of this treatment protocol outweighs any risks or burdens. A weak recommendation indicates that there is some uncertainty to whether the benefits outweigh the risks or burdens.
There are other significant qualifiers regarding the value of the studies or evidence upon which these recommendations rely; component parts of the recommendations are noted as being reliant on either moderate or low quality evidence. Parsing out the significance of this language requires dabbling in the "lingo" of research medicine, but is important to understanding the ACP recommendations completely.
The ACP uses three grades to describe the relative quality of the studies upon which their recommendations rely. High quality evidence comes from randomized control trials that yield consistent, directly applicable results or in some limited cases, from observational studies that yield large effects. Moderate quality evidence comes from randomized trials with limitations or from exceptionally strong observational studies. Low quality evidence is reliant on observational studies or on randomized trials that have multiple serious limitations. It is notable that even low quality evidence is derived from relevant clinical studies.
With the framework defined, it's worthwhile to reexamine the ACP recommendations and pull out the most significant, arguably "core" recommendations: those that are categorized as strong recommendations and which have at least moderate quality evidence to support them: (1) physicians should treat acute and subacute low back pain with heat and with non-steroidal anti-inflammatories or muscle relaxers if any medication is to be provided; and (2) physicians should treat chronic low back pain with exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Markedly absent from these "core" recommendations is any discussion of surgical options or the use of opioids, particularly on a long term basis.
Equally important is the introductory statement to the first recommendation: "most patients with acute or subacute low back pain improve over time regardless of treatment." More physicians are evaluating treatment regimens that called for prescribing medications – sometimes opioids – early on in treatment, along with doing MRIs and other expensive diagnostic tests. But current concerns about costs of treatment and the increased concerns over opioid abuse have caused physicians to reevaluate these previous "first line" treatment protocols. When coupled with studies showing no appreciable favorable difference in outcomes where expensive testing or opioids have been used, physicians are rightly reevaluating their approach to low back treatment, whether caused by personal issues or industrial injury. The passage of time, regardless of other treatment protocols, is a an essential element in recovery.
In reviewing the new ACP guidelines, despite the extensive advances in medical care, it turns out that old solutions may be the best solution. The core recommendations from the ACP are largely a reiteration of the traditional tenets of treatment for low back pain dating back decades: heat, exercise and stretching, and time, along with NSAIDs or muscle relaxers if necessary. In fact, the recommendations seem to be moving back toward the old adage, "take two aspirin and call me in the morning."