- Michele Curatolo
How to manage an episode of low back pain?
A paradox
Nearly everyone experiences at least an episode of low back pain in their life (acute low back pain). Acute low back pain can cause substantial suffering and physical impairments, and is associated with very high social costs due to missing work days and use of healthcare. Despite the enormous frequency and social importance of acute low back pain, we know almost nothing about its causes, and there are hardly treatments that have been proven to be effective by rigorous research.
What causes acute low back pain?
When we experience a low back pain episode, health professional may give us an explanation for the pain and a treatment. However, strictly speaking, most diagnoses are based on hypotheses, and most treatments are unproven. Let's consider the example of "muscle tension", which is frequently provided as an explanation for acute low back pain. This diagnosis is based on the finding of tense/painful spots of the back. However, there is no proof that the tension is the cause of pain. Even if this were the case, we still do not know the causes of the muscle tension. Massage, manipulation, or local injections may be recommended to treat the muscle tension. If these treatments help, one may conclude that the problem was indeed in the muscle, and the treatments were effective. However, these conclusions are not necessarily correct.
Having improved "after" a treatment does not necessarily mean having improved "because of" the treatment
In a very recent study, the probability of recovery from an episode of low back pain was 70% before 1 week, 86% before 3 weeks, 91% before 6 weeks, and 93% before 12 weeks. Because acute low back pain resolves spontaneously in most cases, it is unclear whether the treatment or the spontaneous healing, also called "natural history", leads to an improvement.
Which treatments work?
A comprehensive discussion on treatments is outside the scope of this blog, but let's consider medications. A recent large systematic review has pooled together the results of 98 studies that included 15134 patients, treated with 69 different medications or combinations of medications. The study found very modest evidence for the superiority of medications over placebo or of a medication over another.
Anti-inflammatory medications, such as diclofenac or ibuprofen, are available over the counter and largely used. A recent investigation has revealed that the use of these medications during the acute phase of low back pain may facilitate the development of long-lasting low back pain. This paradoxical effect may be explained by a reparatory effect of the inflammatory reaction on injured tissues; suppressing this process may enhance the risk of non-healing, and therefore persistent pain.
Plenty of other treatments are used for acute low back pain, including massage, manipulation, physical therapy, and many others, but no one stands out as being convincingly and substantially better than waiting for the natural resolution. When back pain is associated with leg pain due to spinal nerve pathology (radicular pain), epidural injections may be recommended. These injections have been shown to help in the short-term, which may be valuable when the pain is excruciating. However, they are unlikely to have benefits in the long-term (read more here).
Since we know so little, what should we do?
There is an overwhelming chance of recovering from acute low back pain. Anxiety and fear that something is damaged in the back are mostly unjustified, and have been shown to be risk factors for persistent pain.
The most important treatment is to be reassured that time will lead to recovery
Seeking professional care is rarely necessary. Tests and specialized treatments are not indicated in the large majority of cases, and will cause costs with questionable benefits. For instance, research has shown that MRI and other imaging, when done in this phase, increase the chance of receiving procedures, such as injections or even surgery. However, the long-term outcome is not affected by doing or not an MRI. Therefore, paradoxically, these investigations may be more harmful than useful (read more here).
Prioritize self-management:
If back pain is the only symptom, do not seek professional care for the first 2 weeks, or longer if there is a gradual improvement
Avoid diagnostic tools, such as MRI
Moderate and intermittent physical activity is preferable to prolonged rest
Medication management should not be aggressive, and primarily based on acetaminophen/paracetamol, if not contraindicated
Anti-inflammatory medications should be avoided or used in a restrictive manner, until evidence is provided that they do not facilitate the progression to long-lasting pain
Non-pharmacological and non-invasive treatments can be tried, knowing that it is unclear whether they will facilitate the recovery, as compared with waiting for spontaneous resolution