If you’ve got lower back pain, you’re not alone. But don’t pop a pill to treat it.
Try exercise, cognitive behavioral therapy, massage, acupuncture and other nondrug treatments first, say new guidelines released this week by the influential American College of Physicians.
The guidelines are based on a review of 150 studies over the past decade.
The review team was led by Dr. Roger Chou, a professor in the School of Medicine at Oregon Health & Science University. He discussed the results with The Oregonian/OregonLive. The interview has been edited for length and clarity.
Q. How prevalent is lower back pain?
A. It’s one of the top four to five things that people go to see the doctor for. Twenty percent of adults report some back pain every year, and up to 80 percent of people have back pain at some time in their life. It’s almost normal to have back pain at some point.
Q. Do the guidelines apply to a temporary strain as well as chronic pain?
A. They’re for both (but) they behave very differently. The vast majority of people who strain their back get better quickly. The guidelines recommend exercise, acupuncture and manipulation but frankly most people don’t need that stuff. They’re going to improve no matter what we do.
Q. And the others?
A. There’s a relatively small proportion that don’t get better. Those are the people who develop chronic lower back pain. The reason this distinction is important is because once the back pain has been present for 12 weeks or more, it doesn’t tend to get better. These are the people (who’ve ended up in the past) having lots of X-rays and procedures and other things done and they end up getting opioids.
Q. So what do the new guidelines recommend that the ones published in 2007 didn’t?
A. For acute (pain), the biggest difference is that the old guideline recommended acetaminophen, which is Tylenol. There’s a pretty good randomized control trial that came out within the last few years that showed that it didn’t appear to be effective for acute low back pain so that’s been taken out. There’s a little bit more of an emphasis on nonpharmacologic treatment for low back pain.
Q. What about for chronic pain?
A. For chronic lower back pain, there are some substantive differences. The first is that the preference is to use nondrug therapies. The previous guidelines they had a bunch of things listed – drugs and nondrugs. They basically didn’t say which to use first. Now the guideline has really shifted in tone to saying use non-pharmacological therapies first and in particular with very strong cautions about using opioids.
Q. Why?
A. The problem with opioids is that they’re not as effective as people think are. There’s no studies proving long-term benefit in terms of six months or a year and most people who are on opioids for chronic low back pain are on these for many years. And the biggest downsides are that we’ve seen a dramatic increase in unintended overdoses from opioids and risk of addiction.
Q. So what’s recommended?
A. They really emphasize nondrug therapies, things like exercise, psychological therapies, even things like yoga, mindfulness-based stress reduction. There are all sorts of interventions like that. I think this is very consistent with what we understand about chronic pain. Chronic pain is not a simple, biologic phenomenon where you can give a pill and someone will get better. Chronic pain is strongly affected by psychological and social factors. Someone who reports the same pain intensity level can be affected by it very differently. Some people are completely disabled by it and others aren’t. A lot of these therapies are aimed at getting people moving and functional and helping them to cope with their pain. We’re trying to get away from this paradigm where you give someone a pill and expect that to fix the problem. We know that it doesn’t.
Q. What kind of movement is recommended for chronic and acute pain?
A. Staying active is one of the best things. Most of the studies show that lots of different types of exercise work. You can do motor control exercises. You can do general aerobic exercise, general strengthening exercise. You can do Pilates. You can do yoga, tai chi. All these things appear to be effective. What you want to find is something that people can tolerate and enjoy so they keep doing it.
Q. And what about psychological therapies?
A. There are a lot of different psychological therapies but the main one that people do is cognitive behavioral therapy. (It’s) focused on fixing incorrect beliefs about pain. If somebody thinks they shouldn’t move because their back hurts, we need to address that. The behavioral part is having people set goals, like getting the mail, walking the dog, attending a soccer game or whatever.
Q. If exercise and cognitive therapy don’t work, then what?
A. There are a lot of things that can be tried. Acupuncture is on the list. There are other things like manipulations, getting manipulations from your chiropractor. You can use medications. They should be used in conjunction with these nonpharmacologic therapies. The exception is opioids. We really want people to be careful who they’re giving opioids to and how they’re monitoring that.
— Lynne Terry
lterry@oregonian.com
@LynnePDX
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