Clinical Evidence Concise

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Chronic Low Back Pain



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Am Fam Physician. 2006 Nov 1;74(9):1577-1579.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See Clinical Quiz on page 1475.

What are the effects of oral drug treatments?

LIKELY TO BE BENEFICIAL

Analgesics

One randomized controlled trial (RCT) showed that tramadol (an opioid) decreased pain and increased function at seven weeks compared with placebo. One RCT showed that tramadol plus paracetamol (acetaminophen) decreased pain and increased function at three months compared with placebo. One small RCT identified by a systematic review showed that diflunisal increased the proportion of persons who rated the treatment as good or excellent compared with paracetamol.

Antidepressants

Two systematic reviews including almost the same RCTs showed that antidepressants decreased pain compared with placebo, but they showed no consistent difference in function. One RCT showed that maprotiline increased pain relief compared with paroxetine.

Nonsteroidal Anti-inflammatory Drugs

One small RCT showed that naproxen reduced pain compared with placebo. One systematic review and one subsequent RCT showed no significant difference in symptoms among different nonsteroidal anti-inflammatory drugs. One small RCT identified by the review showed that diflunisal increased the proportion of persons who rated the treatment as good or excellent compared with paracetamol. Two RCTs showed that cyclooxygenase-2 inhibitors decreased pain and improved function at four and 12 weeks compared with placebo, but the effects were small.

TRADE-OFF BETWEEN BENEFITS AND HARMS

Muscle Relaxants

Two RCTs identified by a systematic review showed that tetrazepam reduced pain and increased overall improvement after 10 to 14 days compared with placebo. Two RCTs identified by a systematic review showed that nonbenzodiazepines (flupirtine and tolperisone) increased overall improvement at seven to 21 days but showed no significant difference in pain. Adverse effects of muscle relaxants include dizziness and drowsiness.

What are the effects of injection therapy?

UNKNOWN EFFECTIVENESS

Epidural Steroid Injections

We found no systematic review or RCT including persons with chronic low back pain who did not have sciatica.

Local Injections

One systematic review showed no significant difference between local injections (anesthetic and corticosteroids) and placebo in short-term pain relief.

LIKELY TO BE INEFFECTIVE OR HARMFUL

Facet Joint Injections

One RCT identified by a systematic review showed no significant difference in pain relief and disability between corticosteroid and saline injections after one and three months.

What are the effects of nondrug treatments?

BENEFICIAL

Exercise

One systematic review showed that exercise improved pain and function compared with placebo or no treatment or other conservative treatments.

Intensive Multidisciplinary Treatment Programs (Evidence of Benefit for Intensive Programs but None for Less-Intensive Programs)

One systematic review showed that intensive (more than 100 hours of therapy) multidisciplinary biopsychosocial rehabilitation with functional restoration reduced pain and improved function compared with inpatient or outpatient non-multidisciplinary treatment or usual care. The review showed no significant difference between less-intensive multidisciplinary and nonmultidisciplinary treatments or usual care in pain or function.

LIKELY TO BE BENEFICIAL

Acupuncture

One systematic review provided limited evidence that acupuncture improved short-term pain relief and function compared with no treatment or sham therapy. The review provided insufficient evidence on the effects of acupuncture compared with other conventional therapies. It provided limited evidence that adding acupuncture to other conventional therapies relieved pain and improved function better than the conventional therapies alone.

Back Schools

One systematic review provided limited evidence that back schools reduced pain and disability compared with inactive treatments (i.e., waiting list control, placebo gel, or written advice) or no treatment within six months, although results suggested that benefits may not persist long term. Three RCTs, identified by the review, that compared back schools with other treatments had mixed results.

Behavior Therapy

One systematic review showed that behavior therapy reduced pain and improved behavioral outcomes compared with no treatment, placebo, or waiting list control. The review and one subsequent RCT provided no evidence of a difference in functional status, pain, or behavioral outcomes among different types of behavior therapy. The review provided insufficient evidence to compare behavior therapy with other treatments.

Spinal Manipulative Therapy

One systematic review showed that spinal manipulative therapy reduced short- and long-term pain and improved short-term function compared with sham therapy, but it showed no significant difference in long-term function after six weeks. The systematic review showed no significant difference in pain or function between spinal manipulative therapy and general physician care, physicaltherapy, exercise, or backschool. Two subsequent RCTs comparing spinal manipulation with exercise or no treatment showed that spinal manipulation reduced pain at six to 12 months, but they showed different results for function. One of the RCTs showed that spinal manipulation increased the number of patients who returned to work at 12 months compared with exercise therapy. Another subsequent RCT showed no significant difference in pain or function between spinal manipulation and exercise.

UNKNOWN EFFECTIVENESS

Electromyographic Biofeedback

A systematic review of three small RCTs showed no significant difference in pain relief or functional status between electromyographic biofeedback and placebo or waiting list control. The review provided insufficient evidence on the effects of electromyographic biofeedback compared with other treatments.

Lumbar Supports

We found insufficient evidence on the effects of lumbar supports.

Massage

One systematic review provided insufficient evidence on the effects of massage compared with inactive treatments or other treatments.

Traction

We found no RCTs on the effects of traction for chronic low back pain.

Transcutaneous Electrical Nerve Stimulation

We found insufficient evidence on the effects of transcutaneous electrical nerve stimulation compared with placebo for chronic low back pain.

Definition

Low back pain is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica).1 Low back pain is defined as chronic when it persists for 12 weeks or more.2 Nonspecific low back pain is not attributed to a recognizable pathology (e.g., infection, tumor, osteoporosis, rheumatoid arthritis, fracture, inflammation).1 This review excludes low back pain with symptoms or signs at presentation that suggest a specific underlying condition. Persons with sciatica (lumbosacral radicular syndrome) or pain caused by herniated disks also are excluded.

Incidence

More than 70 percent of persons in developed countries will experience low back pain.3 Each year, 15 to 45 percent of adults suffer low back pain, and one out of 20 presents to a hospital with a new episode. About 2 to 7 percent of persons with acute low back pain develop chronic low back pain. Low back pain is most common between 35 and 55 years of age.3

Etiology

Symptoms, pathology, and radiologic appearances are poorly correlated. Pain is nonspecific in about 85 percent of patients. About 4 percent of persons with low back pain in primary care have a compression fracture, and about 1 percent have a tumor. The prevalence of a prolapsed intervertebral disk among persons with low back pain in primary care is about 1 to 3 percent.3 Ankylosing spondylitis and spinal infections are less common.4 Risk factors for nonspecific low back pain include heavy physical work; frequent bending, twisting, and lifting; and prolonged static postures. Psychosocial risk factors include anxiety, depression, and mental stress at work.3,5 Having a history of low back pain and a longer duration of the present episode are significant risk factors for chronicity. A recently published systematic review of prospective cohort studies showed that some psychological factors (e.g., distress, depressive mood, somatization) are associated with an increased risk of chronic low back pain.6 Individual and workplace factors reportedly also have been associated with the transition to chronic low back pain.7

Prognosis

Generally, the clinical course of an episode of low back pain seems to be favorable, and most pain will resolve within two weeks. Back pain among persons in the primary care setting typically has a recurrent course characterized by variation and change, rather than an acute, self-limiting course.8 Most persons with back pain have experienced a previous episode, and acute attacks often occur as exacerbations of chronic low back pain. In general, recurrences will be more frequent and severe in persons who have had frequent or long-lasting low back pain in the past.

The length of sick leave because of low back pain is similarly favorable. One study reported that 67 percent of persons who took sick leave because of low back pain returned to work within one week, and 90 percent returned within two months. However, the longer the period of sick leave, the less likely it is that the person will return to work. Less than 50 percent of persons who have been off of work for six months because of low back pain will return to work. After two years of work absenteeism, the chance of returning to work is almost zero.9

editor’s note: Tetrazepam, flupirtine, and tolperisone are not available in the United States.

search date: November 2004

Adapted with permission from van Tulder M, Koes B. Low back pain (chronic). Clin Evid 2006;15:419–22.

 

REFERENCES

1. Van der Heijden GJ, Bouter LM, Terpstra-Lindeman E. De effectiviteit van tractie bij lage rugklachten. De resultaten van een pilotstudy. Ned T Fysiotherapie. 1991;101:37–43.

2. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR publication no. 95–0642. Rockville, Md.: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, 1994.

3. Andersson GB. The epidemiology of spinal disorders. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. 2nd ed. New York, N.Y.: Raven Press, 1997: 93–141.

4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?. JAMA. 1992;268:760–5.

5. Bongers PM, de Winter CR, Kompier MA, et al. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health. 1993;19:297–312.

6. Pincus T, Burton AK, Vogel S, et al. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:e109–20.

7. Fransen M, Woodward M, Norton R, et al. Risk factors associated with the transition from acute to chronic occupational back pain. Spine. 2002;27:92–8.

8. Von Korff M, Saunders K. The course of back pain in primary care. Spine. 1996;21:2833–7.

9. Waddell G. The clinical course of low back pain. In: The Back Pain Revolution. Edinburgh, U.K.: Churchill Livingstone, 1998:103–17.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, U.K. Clinical Evidence Concise is printed twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If interested in contributing to Clinical Evidence Concise, e-mail: CEcommissioning@bmj.com. The complete text for this topic also is available as a PDF at http://www.aafp.org/afp/20061101/bmj.html. The evidence on this topic is available at http://www.clinicalevidence.com/ceweb/conditions/msd/1116/1116.jsp.


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