by Stephen Janz, RN BN BAc MPH – Clinic Director Kenmore Centre for Health
I wonder how many conversations have started by mentioning an aching back! Low back pain is the third leading cause of burden of disease in Australia (1) and the single largest contributor to disability worldwide (2). It is rare to find someone who has never experienced back pain at all. The spine is made up of 33 vertebrae, each separated by a shock absorbing disc and supported by ligaments and muscles. Pain can occur anywhere along the spine. Pain can be associated with muscle strain, joint degeneration or damage, disc bulging and or nerve irritation. No single structure is usually involved in isolation, as muscles, joints, discs and nerves are functionally closely related and impact on each other. The low back is particularly prone to developing pain as maximal forces are transmitted through the spine to the lower couple of lumbar vertebrae when standing and especially when sitting. Poor posture, injury, excessive sitting, inadequate exercise, overstrain, and heavy lifting or awkward movements can all lead to low back pain.
For a problem that is so common it may come as a surprise that there is no general agreement on a single ‘best’ treatment, and there is never any shortage of suggestions from friends. The restriction of codeine to prescription only puts the role of painkillers into sharp focus, and it is interesting that the most up to date guidelines on low back pain do not recommend painkillers as a first choice of treatment (3). The American College of physicians in their 2017 guidelines on acute (less than 4 weeks), subacute (4 to 12 weeks) and chronic (longer than 12 weeks) low back pain recommend that first-line therapy for acute low back pain should include non-drug therapy such as superficial heat, massage, acupuncture, or spinal manipulation (3). For chronic low back pain consider nondrug therapy such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive-behavioural therapy, or spinal manipulation. According to the guidelines drug therapy should only be considered for chronic low back pain when it does not respond to non-drug therapy (3).
These guidelines might seem like a shock for those who usually reach straight for the anti-inflammatories or other painkillers, but it is in line with a growing trend in pain management to avoid medication with potentially unwanted side effects, particularly when they do not address the cause of the problem. The range of recommendations reflects the reality that different people may respond better to some approaches than others, so if you have been living with back pain and not tried some of these recommendations now maybe the time. If you have already been using massage, acupuncture, yoga etc in managing your back pain then it’s good to know the research supports your choice. In particular evidence supports the effectiveness of acupuncture in treating both acute and chronic low back pain (4-7). A 2022 study supports existing recommendation for acupuncture as a possible first line no-drug treatment for non-specific chronic low back pain (8) It is interesting that the most up to date guidelines recommend complementary and alternative medicines (CAM) as therapy to use before medication or more invasive therapy. Perhaps the term CAM has outlived its usefulness.
(1) Australian Institute of Health and Welfare. Impacts of chronic back problems. Canberra. 2016.
(2) Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-30.
(3) Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 04;166(7):514-30
(4) Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013 Feb;29(2):172-85
(5) Taylor P, Pezzullo L, Grant SJ, Bensoussan A. Cost-effectiveness of Acupuncture for Chronic Nonspecific Low Back Pain. Pain practice : the official journal of World Institute of Pain. 2014 Sep;14(7):599-606
(6) Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. AHRQ Comparative Effectiveness Reviews. Noninvasive Treatments for Low Back Pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.
(7) Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196.
(8) Baroncini, A., Maffulli, N., Eschweiler, J. et al. Acupuncture in chronic aspecific low back pain: a Bayesian network meta-analysis. J Orthop Surg Res 17, 319 (2022). https://doi.org/10.1186/s13018-022-03212-3