Review of 301 clinical trials in the British Medical Journal concludes that only one in ten treatments for lower back pain actually work with scientists revealing which are most effective
A scientific review of back pain has identified which drugs and life changes actually work. Four in five people will suffer lower back pain at some point in their lives and for many it is debilitating.
A study of 301 clinical trials, conducted in 44 countries, and investigating 56 different non-surgical treatments has concluded that only one in ten work. The findings, published in the journal BMJ Evidence Based Medicine, concluded that for acute lower back pain – which is severe but short-lived – only non-steroidal anti-inflammatory drugs (NSAIDs) had an effect. These are a class of medications used to relieve pain and reduce inflammation and include ibuprofen, nurofen and aspirin.
For chronic lower back pain – which is less severe but more constant – interventions shown to benefit some people were exercise, spinal manipulative therapy, use of kinesiology tape (KT tape) to reduce pain and improve circulation, antidepressants and transient receptor potential vanilloid 1 (TRPV1) agonists.
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The researchers said that for all drugs the effect sizes were relatively small after finding the pain relief they offer was only marginally better than that achieved with a placebo or dummy pill. The review, by the University of New South Wales in Australia, concluded: “Our review did not find reliable evidence of large effects for any of the included treatments.”
The most common interventions were NSAIDs which were tested in 27 of the trials, opioids in 26 trials, laser and light therapy in 25 trials and acupuncture in 24. Anaesthetics and antibiotics also were not effective. Only NSAIDS produced robust evidence that they had some real benefit.
The NHS website states: “Back pain can have many causes. It’s not always obvious what causes it, and it often gets better on its own.” It recommends staying active and trying ice packs and heat packs. If possible the NHS advises sufferers to try stretching and exercises.
The study showed 80% to 90% of lower back pain is categorised as non-specific because there is no immediately identifiable cause. Leading back pain expert Nick Carleton-Bland, consultant neurosurgeon at the Walton Centre NHS Foundation Trust, said: “The work is important as back pain is the most common symptom known to humankind and the leading cause of disability.
“The review confirms that most treatments for back pain have a limited effect that often there is not one treatment alone that will work. There is no ‘silver bullet’ to back pain management, but small incremental improvements that when used in combination can help the patient with their symptoms.
“The mainstay of treatment for back pain should be exercise, self-management and physiotherapy. At the Walton centre we are evidence-based and use all of these techniques in combination as ‘marginal gains’ – using with topical and oral medications, psychology, patient education and self-management, functional stimulation and acupuncture.
“Multimodal therapy should be used to manage these patients. GP, physiotherapist and hospital specialists should all be aware of this evidence based approach so that we all ‘sing from the same hymn sheet’ and help empower the patient into taking control of their condition and in turn give the patient realistic expectation of the efficacy of the interventions.”
Dr Cathy Stannard, consultant in complex pain at NHS Gloucestershire, said: “The selection of studies for analysis meant that the authors couldn’t make comments about the potential benefits of psychological therapies. It’s important to know that the very real experience of pain is hugely influenced by non-medical factors including social context, trauma, poverty, isolation, poor mobility, emotional well-being and mental health.
“What is as important to people living with pain as the treatments described here is the need for them to have good, empathic relations with their healthcare provider, being believed, having time to tell their story and being partners in their care.
“The study also highlights the benefits of exercise for long term back pain. Exercise improves many aspects of life but is quite daunting for people who experience pain when they move. Spending time understanding the challenges people live with and working out ways of getting mobile should be an important focus for healthcare systems.”
