Low back pain: Part III: Treatment approaches

In this review, a variety of common non-surgical modalities for treating acute and chronic back pain were discussed and their efficacy on outcome analyzed. In addition, surgical treatment approaches for low back pain were described. Back pain remains as one of the most common complaints of patients seeking medical care. Although the differential diagnosis seems extensive, mechanical back pain may account for as much as 98% of low back pain. Unfortunately, in most cases, a precise diagnosis cannot be made even if mechanical in origin. Treatment selection is often empirical, and a multitude of therapeutic modalities are available to health care professionals and/or directly to patients. This widespread availability combined with the complexity of the low back pain syndrome warrants guidelines that are founded on evidence-based medicine. Today, by searching electronic databases, such guidelines can be derived to provide primary care clinicians with information and recommended strategies for improving assessment and/or the treatment of diseases or syndromes in such patients. However, when analyzing the literature on treatment of low back pain, it becomes evident that more research is still needed to investigate the efficacy of both conservative and surgical treatment strategies. Unfortunately, a major difficulty in performing such investigations is ultimately measuring outcomes; e.g., it is nearly impossible to optimize a randomized controlled trial in a surgical patient population. Furthermore, from an ethical standpoint, a double-blind approach and/or the randomization of patients to different treatment groups is difficult to perform, which leads to an obvious flaw in the design of almost all clinical outcome studies on chronic low back pain patients. In spite of these limitations, insightful information on therapy modalities in such patients can be and have been made. In acute back pain, it has been demonstrated that NSAIDs and muscle relaxants can be quite effective treatments. Initially, exercise therapy is contraindicated in cases of acute back pain, but interestingly, bed rest is not considered beneficial for such patients either. In chronic back pain, exercise therapy, manipulation and back schools are all considered effective for improving outcomes. Yet, the specific role of each treatment approach is less clear. A summary of treatment efficacy is presented in Table 3. For the role of surgery in the treatment of low back pain, there is even less clear evidence as to the efficacy of various approaches. In selected patients (i.e., those with either disc herniation with persistent severe symptoms, severe spinal stenosis, symptomatic spondylolisthesis or degenerative disc disease with instability), surgery may be considered the treatment of choice. However, the potential risks of surgery should be weighed against the anticipated benefits. In general, an attempt at the conservative treatment of back pain should be made before surgery is performed as a treatment option. It is critical to understand that every patient responds differently to therapy, and thus, a well-established therapy might not be effective in a given individual patient. In other words, reevaluation of patients in response to their therapy is an important component for the management of patients with low back pain. Additionally, in the chronic patient, psychosocial factors need to be considered as they may affect pain, the ultimate prognosis and potential disability. The complexity of the low back pain syndrome, especially in the chronic patient, may warrant a more rigorous treatment approach. Treatment in a pain clinic where the patient is treated by a pain specialist that consults with or refers to psychologists/psychiatrists, neurosurgeons, orthopedic surgeons, hematologists and others is one approach. Another approach is integrative rehabilitation programs that use various treatment modalities, such as physical and occupational therapy, behavioral modification and patient education, to increase the patient's responsibility. In most patients, this involvement in one's own treatment often leads to improved outcomes by reducing pain, facilitating a more rapid return to function, and improving quality of life. This, in turn, may lead to a reduction in treatment costs by decreased utilization of health care services, decreased numbers of disability and an overall improved work status. In the future, more high quality outcome research is needed to better understand the effects of various treatments on outcome and to justify their use in patients with low back pain.