Review by Carson Berry
This article is part of a series of clinical guidelines sponsored by the American College of Physicians (ACP). It addresses the important issue of low back pain. The Annals of internal medicine have a variety of series on many topics. If you’re interested in learning more about best practices in other fields check them out (if you need CME credits, they’ve got ‘em!)!
Qaseem, A.; Wilt, T.; McLean, R.; and Forciea, M-A. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. DOI: 10.7326/M16-2367
The article is open-source, but if you have difficulty accessing, contact Lindsay or Carson for help!
The article summarized this week was a systematic review of pain management techniques for acute, subacute and chronic low back pain. In the interest of brevity, we will focus on their chronic pain findings.
A medically-relevant qualitative approach was taken in evaluating the strength of each study’s findings. Each type of treatment was grouped as being a “strong” or “weak” recommendation, depending on whether the benefits clearly outweigh the risks/burdens of the treatment (“strong”) or whether there was a fine balance between them (“weak”).
For each treatment, the strength of recommendation was then crossed with the quality of the evidence available at the time of publication (high, moderate, or low). For example, a randomized controlled trial (RCT) without major limitations was considered to be high quality evidence. Overwhelming evidence from observational studies would also be graded as high-quality evidence.
Moderate quality evidence was defined to be an RCT with important limitations, inconsistent results or exceptionally strong evidence from observational studies.
Low quality evidence was defined to be observational studies or case series.
Many non-pharmalogical therapies showed small to moderate improvements in chronic low back pain with rarely reported adverse reactions. Motor Control exercise, Tai chi, progressive relaxation, multidisciplinary rehabilitation, acupuncture, electromyography biofeedback, and CBT all had moderate effects on pain. Small effects could be seen with general exercise, mindfulness stress-reduction, yoga, low level laser therapy, operant therapy, and Spinal manipulation. Despite the fact that their data was gathered from RCTs, much of the nonpharmacologic evidence was of low strength.
Pharmacologic treatments generally had a small to moderate effect on chronic low back pain. NSAIDS and Tramadol specifically, were found to have moderate effect, while otherwise opioids generally had a small effect. Significant differences in the adverse effects were found between NSAIDS and Opioids, making NSAIDS a more logical starting place, before progressing onto Tramadol, and ultimately various opioids if necessary. Generally, the research reviewed for pharmacologic therapy was of moderate strength, suggesting little change with future research.
Several therapies had no effect on pain or function, including TENS, ultrasound, or kinesio-taping, however this was ranked as low quality evidence.
Independently evaluating the strength of the evidence with the strength of the results is a very important technique that many of us sometimes forget to do!
This paper presents a strong case for non-medication management as a first line treatment for chronic low back pain. If a patient fails multiple nonpharmacologic treatments, the authors suggest moving onto pharmacological therapy starting with NSAIDS, and progressing into Tramadol or Duloxetine if necessary. They recommend considering opioids only if the patient has failed all other treatments, confirming much of our clinical knowledge
The array of evidence finding small to moderate effects of non-pharmalogic therapy was often classified as low-quality evidence. By the author’s classification schema, there are many potential contributing factors to this, including difficulty in running RCTs (methodological limitations), inconsistent results, and confounding factors. As we know pain is complex, and (in our experience) treating a diverse cohort of people requires a nuanced approach coupled with skilled practitioners to help determine which treatment is going to be most effective for any specific patient.
As this study relied on previously collected data, they were not able to make direct comparisons in the efficacy of treatments, only report on the found effect compared to most relevant placebo treatments.
Additionally, the risk of addiction and abuse was not addressed for opioid use, which, as we all know, is a very important topic these days in BC and Canada.
Personally, I believe I see these findings in practice every day at CHANGEpain. We have built a remarkable array of non-pharmacological therapies with the goal of not only improving people’s pain, but also decreasing their reliance on opioids. We also certainly acknowledge the role that opioids can have in managing complex cases of chronic pain, in patients who are not able to tolerate other therapies.
While this study was intended for use by the average clinician to guide their actions in treating low back pain, it also serves to justify our research efforts. We are all working on the edge of a developing field; not only are we implementing best practices, we are working to further confirm those practices and add our potentially unique findings to the overall (non-) glamorous clamour of SCIENCE. The ongoing data-collection, review, and publication efforts we undertake are not in vain; we are determining the future of chronic pain care, one day at a time.