As noted in my last column (“Evaluation and Management of Low Back Pain: Part 1,” Psychiatric Times, May 2008, page 32), the American College of Physicians and the American Pain Society released the first comprehensive guideline on chronic low back pain (LBP) based on published evidence.1-3 In the May column, I discussed the guideline recommendations for evaluating patients. Here I review treatment recommendations.
Nonpharmacological and nonsurgical therapies
The guideline divides the therapies it reviewed into nonpharmacological, nonsurgical, and pharmacological categories. The nonpharmacological category includes a wide range of modalities from treatments that patients can perform themselves, such as yoga and exercise, to psychotherapy, acupuncture, and a variety of physical therapy techniques, including heat and laser treatments.
For patients with chronic LBP, the guideline found good evidence to support the use of cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. The last is defined by the guideline as “an intervention that combines and coordinates physical, vocational, and behavioral components and is provided by multiple health care professionals with different clinical backgrounds.”1 Moderate evidence was found for the efficacy of acupuncture, massage, yoga, and functional restoration, which is “an intervention that involves simulated or actual work tests in a supervised environment in order to enhance job performance skills and improve strength, endurance, flexibility, and cardiovascular fitness in injured workers.”1
On the basis of my own experience treating LBP, I generally agree with these recommendations—especially the ones regarding the therapies that patients can use themselves such as exercise and psychological approaches that involve learning techniques to help manage the pain.
I believe that interdisciplinary rehabilitation programs that provide a range of conservative treatment modalities, including psychologically based therapies and physical therapy focused on exercise, are still the best methods for treating chronic LBP and other forms of chronic pain. Unfortunately, true interdisciplinary programs in which the medical professionals involved actually formulate treatment plans together and coordinate therapies are diminishing primarily because of the costs of providing such programs. Furthermore, by necessity, such programs take time to show their benefits.
Patients are bombarded by advertisements for a wide variety of interventional techniques, including surgery, that promise to provide almost instantaneous relief (often, a false promise). Consequently, many people hesitate to commit to programs that require them to actively participate and in which progress can be slow, even though such programs are clearly beneficial with little, if any, risk of adverse effects.
My only reservation is the recommendation for spinal manipulation. Although there are patients who report benefit from this therapy, I still have doubts about whether it provides extended benefit. Furthermore, alone among the recommended therapies, it can cause marked harm to patients if done incorrectly.
I have found transcutaneous electrical nerve stimulation (TENS)—for which the guideline found insufficient support—can be quite beneficial while having very little risk of adverse effects. Although the guideline noted that skin irritation develops in as many as 1 in 3 patients who undergo TENS, I have found that because of the many different types of adhesive patches now available, this is actually extremely rare.
As noted in the guideline, medications are the most frequently recommended intervention for LBP. Of the many medications that have been studied and used for pain, the guideline found the most support for NSAIDs, acetaminophen, and tricyclic antidepressants (TCAs) for chronic LBP.
Other drugs also found to be beneficial included opioids, tramadol (Ultram, Ultracet), and benzodiazepines. Gabapentin (Gabarone, Neurontin) was found to be useful when radiculopathy is present. The guideline specifically noted the ineffectiveness of 1 commonly used type of medication—systemic corticosteroids. Skeletal muscle relaxants were found to be useful for acute but not chronic LBP.
I agree that NSAIDs and acetaminophen are good first-line agents for the treatment of chronic LBP. Obviously, because they are available over-the-counter, they are inexpensive. However, because patients can obtain them without prescriptions, they may be unaware of the marked adverse effects that can be associated with their use, especially with acetaminophen. Because chronic LBP may necessitate extended use of these medications, it is important that health care professionals make sure patients who take them are aware of the risks. Patients should be advised to watch for signs that complications may be developing and, of vital importance, to adhere strictly to daily dose limitations no matter how much relief is being attained.
The benefits of TCAs for a wide range of chronic pain conditions including LBP have been well demonstrated, so it is not surprising that the guideline supports their use. The guideline primarily examined the literature on TCAs and SSRIs. Of the antidepressants, there is by far the most evidence for the use of TCAs as analgesics. Many readers are aware that newer antidepressants that appear to exert their actions mainly via serotonin-norepinephrine reuptake inhibitors (SNRIs), including venlafaxine (Effexor XR) and duloxetine (Cymbalta), also can provide analgesia. In fact, duloxetine was the first antidepressant to be FDA-approved as an analgesic. I have found that the analgesic effects offered by these drugs approach those of the TCAs. Also, these agents have a milder adverse-effect profile. However, there is limited published research on the use of the newer drugs for chronic LBP.
Tramadol, for which the guideline found evidence of efficacy, is an SNRI combined with a weak opioid. It appears that the SNRI is primarily responsible for the analgesic effects.
Although the guideline did find that benzodiazepines offered some benefits, I generally recommend against their use in the management of chronic pain. Benzodiazepines appear to offer very limited analgesia while carrying a risk of abuse that I believe is similar to that associated with opioids.
1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491.
2. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007:147:492-504.
3. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.