The Scandal of Low Back Pain Treatment

In March this year The British Medical Journal (BMJ) published an article on ‘Low back pain in people aged 60 years and over’. The authors rightly remind doctors to have a higher index of suspicion for cancer, infections, and bone fractures in older people, but otherwise the approach to back pain is largely the same as in younger people.

When I was working in general practice I would often see patients with low back pain – it’s a very common symptom. Therefore, it behoves doctors to know something about how to diagnose and treat it, wouldn’t you think?

Unfortunately, this BMJ article, like so much of the medical literature purporting to deal with musculoskeletal problems (disorders of the moving parts of the body: the joints, muscles, ligaments, and tendons), is a testament to the bankrupt general state of knowledge in this area; it’s a counsel of despair and a scandal.

How can this be? Surely doctors must have been taught something about how to deal with such a common problem as low back pain? The sad fact, however, is that most doctors know almost nothing about it: they have little or no idea how to examine patients with this symptom or how to treat it.

Of course, doctors should be able to detect the above-mentioned serious causes of low back pain, but these disorders are rare. What about all the rest: the vast majority of patients with non-serious but disabling and distressing so-called non-specific low back pain? It is this type of back pain that I shall discuss in the rest of this article.

Patronising
The authors patronisingly asks, ‘Why does low back pain matter in people 60 or more years old?’ and in advising about treatment point out that readers should ‘Consider individual patients’ [sic] previous treatment experiences, values, and preferences.’ Pretty obvious, I would have thought. That aside, this sentence with its placement of the apostrophe is clumsily written. They should say, either, ‘Consider the individual patient’s previous treatment experiences…’, or ‘Consider patients’ previous treatment experiences…’

Getting down to the nitty-gritty we are told: ‘Focused history and physical examination are largely the same as for younger adults.’ This is where it all falls down. How do you take a history and carry out a physical examination in a patient with low back pain? Most doctors have no idea.

What is non-specific low back pain anyway?
They have a go at explaining it like like this:

When a specific cause [meaning a rare serious one mentioned above] of low back pain cannot be identified…the term ‘non-specific’ low back pain is often used. Many physicians and patients dislike and distrust this label as a diagnosis.

Of course many physicians and patients dislike and distrust this label as a diagnosis – because it isn’t a diagnosis. It means undiagnosed low back pain. And what’s the good of that?

All the structures of the lower back – indeed, all the structures and tissues of the human body – have a name and known function. It should be possible, therefore, to test each one to see whether it’s normal, or if not, work out a diagnosis and devise logical treatment. This is not always easy (for example, with headache), but the moving parts of the body par excellence are accessible to physical examination – if only you knew how to go about it! With such a common symptom as low back pain, the pain must arise somehow. But the orthodox approach gives up at this point, admits defeat, and invents the concept of non-specific low back pain.

Unfortunately, the writers then demonstrate more ignorance by asking, in a boxed section labeled ‘Education into practice’, the following question:

To what extent do you use watchful waiting [doing nothing] to confirm a diagnosis of non-specific low back pain?

In other words, they’re asking how you confirm a diagnosis of a non-diagnosis.

Haven’t a clue
But it’s even worse than this. The on-line version of the article contains a curious piece of advice about what to tell these patients:

Define non-specific low back pain as pain that is probably caused by muscles, joints, and ligaments.

This is careless writing. Pain cannot be caused by the muscles, joints, and ligaments. Presumably they meant to say that this type of pain probably arises from the muscles, joints, or ligaments. And how can that happen? They haven’t a clue.

Doing nothing
Suppose a woman in her 60s develops pain at her lower back and consults her doctor. The doctor, after asking a few questions and perhaps carrying out a perfunctory physical examination, announces that he thinks (or hopes) no serious disorder is present and makes the non-diagnosis of non-specific low back pain. He then tells the patient to go away but to come back if the pain gets worse or has not improved after six weeks.

The article then advises about so-called ‘management options’, the first-mentioned of which is:

Reassurance that there is no serious cause and that symptoms are likely to improve over time regardless of treatment, and to review after six weeks by which time most recovery should have occurred. (Paraphrased.)

Getting into more detail about this way of doing nothing, the authors defer to NICE guidance which recommends:

Providing information about the nature of low back pain to support self-management, including advice to continue with normal activities and more detailed advice about how to cope with daily activities (such as lifting and carrying shopping, self-care, sleep) and about the role of over-the-counter medicines.

Gentle reader, I am not making this up – this is actually what it says. It’s the blind leading the blind.

How can the doctor provide information about the nature of low back pain when he knows almost nothing about it? ‘Support self-management…to continue with normal activities’ is difficult when your back’s hurting. Then, our good doctor should provide ‘more detailed advice about how to cope with daily activities’ – they’ve already said that – ‘such as…self-care’ – whatever that means.

What’s next? Various ‘non-drug treatments’ are suggested (paraphrased):

Exercise and exercise programmes such as yoga, tai chi, Pilates, general whole-body exercise (walking/running/swimming).

Acupuncture: there is little reliable evidence suggesting sustained benefits.

Spinal manipulation by a trained practitioner (such as a physiotherapist or chiropractor) may have small benefits though these are likely to be clinically unimportant.

Multidisciplinary rehabilitation: intensive programmes combining exercise, psychological, physical, and educational components are designed for patients with persistent pain or disability who do not respond to first-line options.

Thus, patients suffering from low back pain should take up a new hobby such as yoga, tai chi, or general whole body exercise – again, not easy if your lower back’s hurting.

And why should patients with this common disorder be advised to consult a non-medically qualified person, a chiropractor? I regard it as an insult to physiotherapists that they are put on the same level as chiropractors.

Then, drug treatments are mentioned only to be dismissed:

Non-steroidal anti-inflammatory drugs (NSAIDS) – the small benefits are unlikely to be clinically important; paracetamol is unlikely to be effective for low back pain; opioids – prescribe as a last resort; muscle relaxants – the benefits are likely to be clinically unimportant; antidepressants – trials suggest there are no clinically important benefits; anticonvulsants – ineffective for back pain.

Antidepressants for back pain? They’ve got to be joking! And of course anticonvulsants are ineffective for back pain, so why mention them?

The opioid crisis
I wonder how far the opioid crisis in the US and elsewhere is due to overuse of prescription medicines for chronic (long continuing) back pain. Patients do not wake up one day with chronic pain: it means they have untreated or refractory acute (starting suddenly) pain.

If a patient with so-called non-specific low back pain does not recover within the arbitrary period of six weeks, the doctor, now at his wits’ end, may prescribe an opioid (morphine-like) drug. But since the underlying cause has gone unidentified and untreated, the demand for further strong painkillers may continue. Thus it’s all too easy for such a patient to be labelled with chronic pain and become addicted to opioids.

On the other hand, if these patients had been treated effectively in the first place and the pain promptly relieved, then they may never have become chronic pain sufferers.

What, then, should be done?
How do you make a diagnosis and provide effective treatment for patients with low back pain? You take a history and perform a physical examination, but how do you do that? It’s quite straightforward when you have it demonstrated by an expert.

In the same way as I learnt how to diagnose and treat shoulder disorders from Dr James Cyriax, with his systematic approach it’s not difficult to work out the source and mechanism of low back pain. Most cases can be confidently ascribed to displacement of an intervertebral disc (slipped disc), jamming (subluxation) of one or both sacroiliac joints, or strain of the ligaments connecting the joints of the lower back. Logical treatment follows and can be carried out on the spot: spinal manipulation, epidural injections of local anaesthetic and cortisone, or sclerosant injections to strengthen the ligaments. In the case of manipulation and epidural injections it is gratifying for the patient (and, indeed, for the doctor) that patients often can walk out of the consulting room with their pain eliminated or much reduced. Until retirement I used these methods in my daily practice with regularly good results and no adverse effects; they are within the scope of any interested doctor.

I hasten to add that this is not something clever or difficult: it’s based on simple principles of applied anatomy and logical treatments for the correct diagnoses.

What about the evidence?
The views in the BMJ article are supposed to be backed up by their seventy-one references to the medical literature. But the problem is that all of them dealing with diagnosis and treatment are accounts of investigations in non-specific low back pain as if it is a single disease entity. Manifestly this is not the case. Thus, we have ‘evidence’, for example, that ‘spinal manipulation may have small benefits though these are unlikely to clinically important.’

The trials claiming to support this dismissive conclusion are asking the wrong question. Instead of seeking to discover whether spinal manipulation is helpful in low back pain, they should be asking: for which type of low back pain is manipulation helpful?

Alas, such trials of manipulation and other effective treatements have not been done because of widespread ignorance of how to make a diagnosis in the first place.

Haven’t a clue – Part II
As an example of the appalling ignorance of most doctors about low back pain, an on-line response to this BMJ article was published shortly after. The writer recounted that he had suffered a broken femur (thigh bone) 14 years previously and subsequently developed right-sided low back pain. He was treated with physiotherapy and when the pain worsened he attended a chiropractor for spinal stretching exercises, though these only had a limited effect. Then the penny dropped: he underwent ‘gait analysis’ which revealed, hardly surprisingly, that one of his legs was shorter than the other. A heel raise solved the problem. (Gait analysis is performed by running on a treadmill for 30 seconds while one’s stride is recorded and analysed.)

However, if this patient had consulted a Cyriax trained doctor, assessment for discrepancy in leg lengths would have been performed as part of the routine physical examination and the needed heel raise prescribed straightaway.

Text © Gabriel Symonds

Photo courtesy of Chuttersnap on Unsplash