Chronic Pain?
Sarah Ellefson, PT, DPT, OCS
Low back pain is a leading cause of disability worldwide with an estimated 540 million people affected at any given time (1). A recent paper published by a team of global experts on low back pain presented evidence for the effectiveness of current treatments and a worldwide call to action. Why the call to action, you might ask? Globally, what we are doing isn’t working.
Currently, pharmacological interventions are the most frequently recommended treatment option for people suffering from chronic non-specific low back pain (2). This trend continues despite a growing body of research stating the ineffectiveness and risks associated with pharmacological interventions. A systematic review published in 2011 found low quality evidence for the effectiveness of opioids and NSAIDs on pain and function. Adverse effects were extensively reported in association with pharmacological intervention, ranging from dizziness and headache to tachycardia and tremor (2). Even in the midst of low quality evidence for their effectiveness, a 2014 study reported that more than half of people presenting to United States emergency rooms with low back pain are prescribed opioids (3).
In 2016 the United States Center for Disease Control (CDC) updated their guidelines for prescribing opioids for chronic pain based on a systematic review of their effectiveness and risks, recommending nonopioid therapy as the preferred treatment for chronic pain (4). Despite similar recommendations worldwide, a gap exists between evidence and practice and this gap results in potential harm and excessively utilized--and arguably wasted--healthcare resources.
Current evidence suggests that nonpharmacological interventions are most effective for treating chronic low back pain. Exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation have been shown to improve outcomes in both the short and long term (6). Early referral to Physical Therapy for low back pain is associated with significantly lower utilization of advanced imaging, lumbar injections, surgery and opioid use as well as 60% lower cost of care (7). As healthcare consumers and providers worldwide, we need to shift our focus to conservative and movement-based approaches for the treatment of chronic low back pain. Current research suggests that initial management of low back pain should avoid pharmaceutical intervention and should instead utilize multidisciplinary rehabilitation as a first-line treatment choice. We can in turn prevent adverse effects associated with NSAID and opioid use, improve long-term outcomes with regard to disability and reduce health care utilization and costs.
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al.; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 06 9;391(10137):2356–67. doi: http://dx.doi.org/10.1016/S0140-6736(18)30480-X PMID: 29573870 3.
Kuijpers, T., van Middelkoop, M., Rubinstein, S.M. et al. Eur Spine J (2011) 20: 40. https://doi.org/10.1007/s00586-010-1541-4
Jeffrey Kao MC, Minh LC, Huang GY, Mitra R, Smuck M. Trends in ambulatory physician opioid prescription in the United States, 1997−2009. PM R 2014; 6: 575−82.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: United States, 2016. JAMA 2016; 315: 1624−45.
Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al.; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 06 9;391(10137):2368–83. doi: http://dx.doi.org/10.1016/S0140- 6736(18)30489-6 PMID: 29573872 4.
Noninvasive Treatments for Low Back Pain, Comparative Effectiveness Review No. 169, prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I for the Agency for Healthcare Research and Quality, February 2016. Available at www.effectivehealthcare.ahrq.gov/low-back-pain.
John D Childs, Julie M Fritz, Samuel S Wu, Timothy W Flynn, Robert S Wainner, Eric K Robertson, Forest S Kim, Steven Z George. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research, 2015; 15 (1) DOI: 10.1186/s12913-015-0830-3
