New clinical guidelines prescribe exercise as first-line therapy for lower back pain

20170217120000, Vi-Jean Khoo
New ACP guidelines recommend yoga and exercise for management of back pain
When patients with lower back aches consult Dr James Weinstein, a specialist in back pain and chief executive of Dartmouth-Hitchcock Health System, he simply says: “Take two aspirin and don’t call me in the morning.”

Doctors and patients are inclined to believe that a simple prescription of painkillers are effective for ailments like back pain, and for good reason – evidence-based guidelines for pain management often suggest pharmacologic therapies, with nonsteroidal anti-inflammatory drugs (NSAIDs) remaining as a popular choice for first-line treatment.

However, the updated guidelines published by the American College of Physicians (ACP) are advising doctors to avoid medication as the first-line treatment for back pain – a huge shift from its previous recommendations.

Little benefit from painkillers in treating back pain

The new guidelines were published in the midst of the epidemic of opioid addiction in the United States, a circumstance which has led many experts to review prescribing practices of painkillers and other forms of non-invasive treatments for back pain.

Analysing 35 peer-reviewed trials on NSAIDs for back pain, Australian researchers reviewed data from a total of 6,065 patients only to find that the effects of the analgesic was too small to be considered clinically significant. Not only do NSAIDs offer little to no benefit for back pain, the researchers also found that patients who were on the medications were 2.5 times more likely to suffer from gastrointestinal side effects.

“We are not arguing that no pain relief should be used, but people using these types should be aware the benefits are small and that their side effects can be harmful,” said lead author associate professor Manuela Ferreira.

Exercise and yoga as first-line treatment, recommends new guidelines

The revised ACP guidelines are encouraging doctors to recommend heat therapy, yoga and exercise, as well as acupuncture to patients as first-line therapy for back pain before resorting to medication. Doctors are also urged to reassure patients that their back pain will improve over time, regardless of the treatment option.

In truth, these alternatives are unknown to healthcare providers, as there is evidence that back pain – amongst many conditions – can be managed without drugs or surgery.

The Handbook of Non-Drug Interventions (HANDI) by the Royal Australian College of General Practitioners (RACGP), for example, is a ready-reference publication that outlines such treatments for various ailments. Examples include the use of honey for coughs, to splints for osteoarthritis, and even exercise therapy for the management of acute and chronic back pain.

So why are doctors not recommending these interventions more often?

Helping patients stay active despite pain

According to Professor Chris Del Mar, an evidence-based medicine specialist at Bond University in Queensland, 99.9% of acute back pain self-resolves, but patients who are in pain would like something to relieve it.

“It’s hard for doctors to say to people, ‘I don’t have anything that will make much of a difference to your back pain, so grit your teeth and bear it’,” he said. “People want to hear, ‘I’ll give you some pills and we’ll make you feel better’, so it’s a cognitive bias.”

“That’s one of the reasons we tend to use treatments, even when they’re not effective,” he explained.

Incentives by the industry also push doctors and patients to take more medications and undergo more unnecessary scans, according to Dr. Rick Deyo, a spine researcher at the Oregon Health and Science University, who is an author of the new guidelines.

“There is marketing from professional organisations and from industry,” he said, adding that medical insurances do not pay for such remedies.

“Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients,” said ACP president Dr Nitin Damle.

According to Dr. Christopher J. Standaert, a spine specialist at the University of Washington and Harborview Medical Center, patients tend to avoid usual activities for fear of worsening their back pain, and doctors should help, not by prescribing drugs, but by educating patients to staying active despite their pain.

“What we need to do is to stop medicalising symptoms,” said Weinstein. “Yoga and taichi, all those things are wonderful, but why not just go back to your normal activities?” he said.

“I know your back hurts, but go run, be active, instead of taking a pill.” MIMS

Read more:
Gaps in medical knowledge: Do doctors really know best?
Placebo or nocebo: The importance of doctor-patient conversations
Is acupuncture a medical sham or a genuine treatment?

Sources:
https://www.nytimes.com/2017/02/13/health/lower-back-pain-surgery-guidelines.html?_r=0
https://www.theguardian.com/society/2017/feb/03/back-pain-medications-have-little-benefit-and-may-cause-harm-research
http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
http://www.telegraph.co.uk/science/2017/02/13/prescribe-exercise-not-drugs-lower-back-pain-say-us-health-chiefs/
http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597.short?g=w_ard_ahead_tab
http://www.business-standard.com/article/current-affairs/drugs-don-t-cure-everything-doctors-can-be-helped-to-prescribe-alternative-117021100186_1.html
http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercise-for-acute-lower-back-pain/
http://www.racgp.org.au/your-practice/guidelines/handi/interventions/musculoskeletal/exercise-for-chronic-low-back-pain/