Noninvasive treatment for low back pain: a new clinical guideline from ACP
The American College of Physicians (ACP) has released 3 recommendations regarding the noninvasive treatment of acute, subacute, and chronic low back pain in a clinical practice guideline published in the Annals of Internal Medicine.
The ACP developed the guideline from randomized, controlled trials and systematic reviews published through April 2015 that focused on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. The agency evaluated outcomes including reduction or elimination of back pain, improvement in back-specific function, improvement in health-related quality of life, reduction in work disability, number of back pain episodes, patient satisfaction, and adverse events.
Recommendation 1
The ACP recommends that clinicians and patients should select nonpharmacologic treatment with superficial heat to treat acute or subacute low back pain, given that this pain usually improves over time. Clinicians can also treat acute or subacute pain with massage, acupuncture, or spinal manipulation. Nonsteroidal anti-inflammatory drugs or muscle relaxants should be selected if pharmacologic treatment is required (Grade: strong recommendation).
“Clinicians should reassure patients that acute or subacute low back pain usually improves over time, regardless of treatment,” the study authors wrote. “Thus, clinicians should avoid prescribing costly and potentially harmful treatments for these patients, especially narcotics. In addition, systemic steroids were not shown to provide benefit and should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms.”
Recommendation 2
For patients with chronic low back pain, the ACP recommends that patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Other treatments include tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (Grade: strong recommendation).
Recommendation 3
The ACP states that clinicians should consider pharmacologic treatment in patients with chronic low back pain who have an inadequate response to nonpharmacologic therapy, using nonsteroidal anti-inflammatory drugs as a first-line therapy or tramadol or duloxetine as a second-line therapy.
The agency notes that opioids should only be considered as an option in patients who have failed the other treatments, and only if the potential benefits outweigh the risks. Clinicians should discuss the known risks and realistic benefits of opioid use with their patients (Grade: weak recommendation, moderate-quality evidence).
“Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as TCAs [tricyclic antidepressants] and SSRIs [selective serotonin reuptake inhibitors],” the authors concluded.
Filed under: General Problems
Pain, it is why people go to the doctor. Chronic pain, it can be argued chronic pain is the result of failure to properly treat pain & disease resulting in chronic pain. Now doctors don’t want to treat pain with effective means, arguably creating more chronic pain and offer zero solutions for those who’ve failed all surgical, alternative and non opioid means. This is already causing unspeakable misery & unnecessary suffering. How can anyone trust a doctor who watches them suffer?
Very well put.
Very well said! In a word, the new ACP recommendations are ‘torture.’ The ACP, group practices and individual medical providers are committing acts of torture and violating basic human rights when they deny legitimate patients in pain (documented clinically and with medical diagnostics) the right to appropriate pain medications which have been proven effective for years at reducing pain. If a patient prefers to take oral opioid medications in lieu of alternative and holistic therapies, they have a right to make that choice. The side effects and risks should be fairly explained so there can be an open and honest, and PRIVATE, opportunity for discussion and decision making between the doctor and patient.
How can ACP make these recommendations AT ALL COSTS, when the COSTS for these treatments are not all covered by most medical insurance companies? In fact, MOST of the recommendations require significant and ongoing out of pocket costs to the patient. Medicare does not reimburse for acupuncture, biofeedback, hypnosis, massage therapy …!!!
When are we going to insist that our trusted individual medical doctors make their own recommendations for patient care on a case by case basis?
More importantly, chronic pain patients who have successfully been treated with opioids for LBP and other chronic pain like CRPS require continued access to these opioid medications. Pain patients are NOT addicts. Most addicts are not chronic pain patients; they are addicts with a disease in their own right that must be treated without imposing restrictions on those patients who continue to comply with doctors’ orders.
How many of you here suffering from lower back pain have already been through the 3 levels of step therapy they’ve listed here?
How many of you have gone above and beyond these 3 suggest levels of suggested therapies by agreeing to and having Non evasive surgical procedures and or even having stimulator implants?
How many of you now are in much worse shape than you were prior to Spinal Manipulation, Steroid Injections, Non Evasive surgeries, or Spinal Cord Stimulator Implants?
I’m not sure if my situation is any different than any others out there, so I would honestly like to find out. So with that in mind, here is my full story.
My life filled with pain really started about 14 years ago after a serious slip and fall accident at work. In February of 2003 I was the General Manager of a nation wide moving truck company store in Elkhart Indiana. Needless to say the greed of this particular company with orange and white trucks and trailers is accessive so payroll allowences for these company owned stores is very low. So most week days I worked alone from 6 am to 5 pm doing everything from managing the store, installing hitches, fixing some mechanical problems with moving trucks and even clearing snow from the parking lot.
One very cold and snowy morning I arrived at my store in the middle of a blizzard. After doing the opening process inside the store and getting my computer systems up and running, I checked my confirmed reservations for the day and pulled the keys I needed for the morning truck rentals. I grabbed my snow broom, gloves and the keys then headed out to the lot to get the trucks warmed up and pulled for my morning customers. I liked to be prepared so my customers were at least happy with the service they received from me, even if they were disapointed with the equipment they were getting.
So first I went out brushed off the 2 smaller trucks and pulled them up to the dispatch lane and left them running to warm up.
Next, I also had a large truck rental, So I grabbed those keys and headed bacl out. As I was walking out to the big parking lot located about 200 yards from the store, I hit a huge frozen mud puddle with a light coating of snow over the top of it. Suddenly, I was looking at my feet pointing towards the sky and I came slamming down flat on my back on the solid ice. It knocked the wind out of me and I couldn’t move. Finally after I caught my breath I tried to get myself up, it felt like a knife was being stabbed into my lower back rigth above my tail bone and off to the right side. I tried and tried but I couldn’t get up. Every time I would attempt to move my feet up under me, it would take my breath away again. So at that time I started crawling back to the store, inching along on my hands and elbows.
Remember, it’s snowing and blowing, plus its only about 10 degrees outside and I’m on the ground crawling and can’t get back up, and I’m also at this store all alone. After about an hour of of inching along, I heard a voice calling for me. It was one of my employees coming in to get her work schedule for the week after I didn’t answer the phone, and thank God she showed up. I called back to her and she came right over and helped me get back to my feet and into the store.
I was the manager and it was my responsibility to file an incident report before I could go to the doctor. So the first thing I did was to file an accident report on the computer and call my district, (Marketing Company) office to report what had happened to my boss. I was told that I had to go to the local Occupational Clinic down the street because that was who the company has setup to treat workman’s comp injuries. Of course it was all about drug testing and that’s who the company got their results from the quickest which was no problem to me because I didn’t use drugs anyway.
I asked the office manager how I was supposed to get there because I could barely walk let alone drive. She told me to call one of my employees to come and take me or to call my wife. Remember, it’s a total BLIZZARD outside and my wife would have had to drive 40 miles just to get me and take me to their doctor. Lucky for me once again, my employee called her father who was also an employee of the same company but at the South Bend store, he only lived a mile away from my store so he came and took me to the clinic.
So, more than 3 hours after my accident I got to the clinic. I explained my situation and the pain I was in, they handed me a pee cup and sent me to the bathroom before they would treat me. Guess what? I peed blood. Then my lower back was x-rayed and I was told that I didn’t have any broken bones but I bruised and strained muscles in my lower back and I would need extensive physical therapy and medications. I asked about the blood in my urine and he told me it was more than likely caused by an infection that was irritated by the fall. This doctor told me that he wouldn’t worry about it and prescribed me Amoxicillin, Muscle relaxers, Ibuprofen and 30 vicoden 5/500s, then setup an appointment with the physical therapist and sent me home.
Well the blood continued for a couple days so I went to my family doctor who set up an appointment at the hospital for an examination of my insides, it ended up being from Blunt Force Kidney Trauma. My lower back still continued to cause problems and with the injury to my kidneys, I ended up off of work for over 3 and a half months. No Cat Scan, no MRI and no testing for nerve damage was ordered by the Workman’s Comp doctor. It was my family doctor who ordered the CT scan and U/A tests and discovered the Blunt Force Kidney injury. My family doctor treated me for it the kidney injury but at that time Workmans Comp said I had to use their doctor to treat my back injury, then they declined to pay for extensive testing like an MRI for my back injury.
Throughout my Tenure at this company I continued to have back and started noticing neck issues but I was released to return to work by the insurance company doctors 3 and a half months after my injury, so new medical issues had to be covered by my own heath insurance.
I had my first MRI in 2009 and the extent of my injury 6 years earlier became more clear. It turned out that I had suffered intensive soft tisdue and minor nerve damage in my L2 through L7, which eventually began my issues of Degenerative Disk Disease, Spinal Stenosis, 2 bulging and 1 herniated disk along with nerve damage. But I was also having neck issues so my doctor ordered an MRI there too. Turns out that the fall 6 years earlier had Damaged vertebrae in my neck worse than in my lower back but the pain in my back and kidneys at the time of the injury outweighed the neck pain. The MRI showed that I had 3 mended fractures in my C3, C4 and C5 then bulging in both C6 and C7. MRI also showed a severe narrowing of my spinal column in all 5 disks and substantial nerve signal loss throughout my hands and arms.
Of course it was my family Doctor who ordered these MRI’s because of the constant pain and the fact my hands would just open up and I often dropped what ever I was carrying. This was also the time that this truck rental company decided that if I couldn’t preform my full duties as they saw fit, that I was no longer valuable to them so they terminated my employment.
Being terminated really didn’t Upset me that bad because I was ready for a career change anyway. I just needed to get a job that I didn’t have to do constant heavy lifting, and one that didn’t require me to work the continuous 62 hours a week that often turned into 70 and 80 hours a week that the rental company required of its General Managers. I needed to find where the employer takes workplace safety seriously and cares about their employees. Next stop Sous Chef.
I have enjoyed cooking all my life and have always taken pride in everything I’ve cooked and served, either at home or the American Legion I often volunteer at. That’s when I found a casino resturaunt to go and work for and start my cooking career in 2010. Almost immediately the executive chef took me under his wing and I moved up the ladder very quickly to become a sous chef in less than a year. Then in early 2013 my back and neck pain started getting much worse. After a lot of testing and going through the entire step therapy fiasco, I was told that injections and implantants are my best and probably only option. So starting in January of 2013 and having the final of 8 surgical procedures on December 5th of 2013, I am now totally disabled at the age of 51. My pain is constant and I rarely sleep anymore. My implants help with minor extremity pain but do not touch the deep bone and tissue pain I have in both my neck and back. I filed for SSDI in March of 2014 after I attempted to return to work when I was released in early March.
My disability stems from my previous years surgeries and after my release I could only stand to work for less than 2 weeks before I had to give up my dream career. I not only have the extreme pain in both my neck and back, but now I have knee, elbow, hands and hip pain along with frequent migraine headaches. The spinal cord stimulators in both lumbar and cervical that were supposed to ease my pain have caused much more extreme pain.
Of course, I’m still fighting for my SSDI and have been denied twice even though I can’t stand on my feet for more than 15 or 20 minutes at a time. If I walk 75 to 80 feet, I have to sit down and rest. Climbing the 4 steps to get into my house is a serious chore and all my doctors have put a 10lb maximum lifting restriction and documented that fact. The Conservitive Asshole Judge who denied my claim sat in the waiting room before my hearing and talked with a man who I didn’t know at that time was the witness from DOT. They sounded like they were good or even best friends, they talked about golfing and a new car that the DOT Wittness had gotten, and they did this right before my hearing. Then they went into the hearing room and acted like I was just there to get a free ride.
Even though this judge agreed that I am Disabled, his decision was that I could still hold a job in either the fast food industry or house keeping in a motel. Remember, I am on a medically documented 10 pound lifting restriction. I am unable to stand more than 15 or 20 minutes at any one time, and I can’t walk more than 70 or 80 feet without a rest, then bending and twisting is nearly impossible. Then, the judge cut me off constantly during my testimony 3 different times and his written recording contradicted the audio recorded hearing. My attorneys are working on my appeal but I’m still waiting.
But enough bitching about my SSDI when my real point is both work place safety and the improper medical treatment that employees receice after an injury.
This is my advocacy. Disabled workers who were under diagnosed and under treated at the time of their injury. To this day I believe that I would not be disabled today if at the time of my injuries I would have had proper medical treatment and therapy. I would not suffer the pain I do today and everyday if workmans comp and the company I worked for would have approved and paid for needed medical diagnosing and therapy.
So, articles about alternative therapies or step therapies just upset me. If this government ever needed to focus on anything, the prevention of injury needs to high on their priority list. Workplace safety and Workmans Comp treatment of injured employees needs to be investigated for coruption and stiff fines for failure to comply need to be put in place and enforced.
If they want to prevent opioid use. They should prevent the injuries that lead to the need for opioid use.
And who is going to pay for all this wonderful, alternative Tx? I can tell you that while it’s non-invasive at the level of the back to low back, it’s highly invasive at the level of the superficial right buttock, specifically in the folded leather pouch that many American men carry in the artificial layer of plant fiber or synthetic fiber material that comprises this pseudo-integument pocket, riding a few millimetres over the surface of said right buttock. I have no problem with utilization of other modalities when they are proven safe and effective. My problem here is that this issue is politicized that I tend to not believe these allegedly scientific treatises that are trotted out by the various expertocrasies until I discover if the study was well designed and free of confirmation bias. Said confirmation bias is often detectable by a time-proven technique that is as old as civilization itself and known by its contemporary moniker “Follow the Money”.
What I’d like to know is what is really driving the current witch hunt against opioids. In prior ages, it was the puritanical sense that if it was making one feel good because it was aligned with the “benefits” of a life of piety and aligned with the sin cleansing habit of hard work and self-denial, then it was ok, but if not, then it was of the devil. My question is who is the devil here in the 21st century, or morse specifically, who stands to make a great deal of money and experience a huge increase in power as a result of this current act of political theater? For a while, I thought that the DEA and the judicial/correctional industrial complex was driving this as the War on Drugs (aka the Drug Lord Price Support Program) largest benefactor, Cannabis, is going away. Then it occurred to me that this current charade has a shelf life of maybe five to seven years before it all falls apart. So my original question remains. Who is really benefiting from this?