Low Back Pain Treatment Guidelines: Time to Go Holistic?

What the American College of Physicians Recommends

Woman receiving back massage
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For many people, conventional medicine fails to satisfactorily relieve pain. This may be one reason why the use of alternative medicine and holistic therapies continues to rise in the United States.

Americans have lots of low back pain. In fact, it’s one of the leading reasons for visits to the doctor’s office and missed work days, as well as the most common cause of job-related disability, according to the National Institute of Neurological Disorders and Stroke.

Additionally, the National Center for Complementary and Integrative Health, an agency within the National Institutes of Health, which is a part of the federal government, cites musculoskeletal and back pain as perhaps the strongest drivers of alternative medicine use.

Spine Medicine in the U.S. 

For the most part, though, the medical establishment is entrenched in more allopathic-type treatments such as medications.

The list of conventional treatments commonly given by physicians to their pain patients includes, among other things, narcotic drugs. Otherwise known as opioids, these medications may possibly lead down a path of addiction if you, your doctor and your pharmacist are not careful.

The good news is that most back pain goes away on its own or by faithfully following a good quality exercise program. The bad news (potentially) is that the first thing your conventional doctor may do is offer you an opioid for your pain—even if the intensity is only mild or moderate.

But the CDC says that doctors should carefully consider the benefits of any treatment in relation to possible health problems that may result. In the case of narcotic pain relievers, if your doctor expects the good the drug will do you—in terms of both pain relief and daily physical functioning—will be greater than the risk for addiction, constipation, and other associated side effects, then opioids may be worth considering.

Keep in mind, though, that opioids have really only proven themselves effective for short term, severe pain. For long term or mild to moderate pain, there are other options that may produce better results.

If you’re taking opioids for pain, you should know that your doctor is supposed to monitor your progress throughout the treatment. Your strength and your capacity for physical activity in daily life should improve, and your pain levels should decrease. Otherwise, it may be best to suspend the opioid therapy, the CDC says.

And finally, the CDC recommends to doctors that before and during the treatment, they speak with you about the risks and benefits of taking opioids.

Other allopathic treatments commonly recommended to patients complaining of back pain include surgery, implanted pain relief systems, and to a lesser extent, physical therapy.

To be fair, implanted spinal cord stimulators tend to get good reviews from patients with chronic intractable back pain who have these devices put in. And for less severe pain, a course of physical therapy often proves helpful—for those who do their homework, that is.

How Does Your Doctor Know What to Recommend in the Way of Treatment?

Generally speaking, medical providers make a lot of money on such treatments, yet statistics show that spine patients do not always get better.

The money factor may be what’s behind the snail’s pace at which powerful medical and public health establishments are progressing in the race towards safe, effective, non-invasive treatments that satisfy pain patients on their own terms.

So how do doctors decide which treatments to recommend to you? One determinant may be the provider’s particular specialization. If you go to a neurosurgeon for a consult, for example, you may well get neurosurgery suggested to you as the thing that will abate your symptoms. But other options may exist from which you can choose.

Plus, this is the age of the niche.

Your surgeon may possess extraordinary skill in one type of spine procedure, but only average or slightly above average skill in others that are related. (This is likely because the surgeon performs that one procedure over and over again.) That said, the particular technique (or philosophy of surgery) at which the doctor excels may not be the best fit for you given your age, condition, personal preferences, and the type of back problem you have.

Let’s take disc surgery as an example. Some surgeons have spent lots of money to learn how to perform disc replacement, which is a relatively new type of procedure. Others, perhaps those who have been in the industry a bit longer, stick with the tried and true spinal fusion. Neither spinal fusion nor disc replacement are perfect in terms of safety and effectiveness, so rather than accepting just one provider’s view on what your treatment should be, it may be in your best interest to research your options more thoroughly before committing.

And finally, the top medical institutions are in the habit of producing guidelines for doctors to (optionally) follow. You, as a patient, may (or may not) benefit from these recommendations in a trickle-down sort of fashion. Guidelines for back and neck problems are published by organizations such as the American Physical Therapy Association, the American Society of Interventional Pain Physicians, American College of Physicians, and others. Depending on the exact spine problem, and who the publisher is, the guidelines mostly suggest drugs, surgery, injection therapy, and/or physical therapy as treatment. Traditionally, they've given little credence to holistic therapies.

An Holistic Slant to Pain Treatment May Be on the Horizon

As of early 2017, change may be coming.

Much buzz around the Internet and on TV news programs was generated in February and March of 2017 when the American College of Physicians published a guideline that, among other things, recommended several holistic therapies as low back pain treatments. These included massage, acupuncture, spinal manipulation, tai chi, yoga, and heat. The guideline is evidence-based, meaning that the recommendations were synthesized from a systematic review of results from high quality (randomized, controlled) studies that evaluated treatments. Researchers wanted to know which treatments produced the best results for things like getting rid of back pain, being able to physically function, improving quality of life, reducing disability and returning to work, and more.

The researchers were also looking for information on side effects and complication rates, as well as how satisfied patients were with each treatment.

This guidelines covers all types of treatments—not just holistic therapies—for acute, subacute and chronic low back pain. Its recommendations of specific holistic treatments differs according to the type of pain. The authors of the guideline said they did not have enough evidence to speak either way on pain that is referred from the spine, which is called radicular pain and is often caused by a herniated disc.

Now, before you cheer wildly (if, indeed you are a person who would prefer holistic care over the allopathic approach), remember that this is only one medical society’s recommendation. In other words, holistic therapy as a conventional pain treatment option that can be prescribed to you by your doctor is not a done deal.

How Close Are We to Widespread Guidelines That Include Holistic Health?

Other organizations, such as the American Medical Association and the Joint Commission (an accrediting agency that sets treatment standards for hospitals) have also, in the past, issued statements.

The natural medicine coverage in these and similar reports can be unpredictable. Sometimes, therapies with which you may be familiar (chiropractic, massage, acupuncture, mindfulness, yoga, for example) are specifically named, but the report stops short of requiring or strongly recommending these as viable first line treatments. Other times, the list of holistic treatment types is much smaller, but their use is more strongly encouraged.

“The language often changes as these recommendation documents get produced, and where the list of holistic therapies is rich with choices, when the final comes out fewer are mentioned,” says John Weeks, publisher of the Integrator Blog News & Report.

For example, in November 2014, the Joint Commission issued the “Clarification of the Pain Management Standard” which, in Weeks’ words, “elevated the importance of non-pharmacologic approaches. Acupuncture therapy, massage therapy, chiropractic therapy, cognitive behavioral therapy, and osteopathy were among the methods explicitly called out,” he says.

Then, in 2017, the Joint Commission produced the next draft of their Pain Standard. You might think that it would be a continuation of the Clarification document from three years earlier, one that includes, and even fortifies the 2014 list of holistic treatments. Instead, although more access to such treatments was recommended, the number of holistic therapies cited is actually smaller.

For this reason, Weeks comments, the latest draft is disconcerting. “Neither acupuncture nor massage, for instance, are specifically called out,” he notes. Weeks adds that when a therapy isn’t mentioned specifically, few doctors will be inclined to adopt it into their practice or recommend it to their patients.

Another example of this changing language phenomenon, according to Weeks, is the CDC’s 2016 draft guideline for the prescription of opioid pain medication. (The final has since been released.) He says, “the Guideline includes this wonderfully transformative language: ‘Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.'"

But, as Weeks mentions in the draft, complementary and alternative therapies (e.g. spinal manipulation, massage, and acupuncture) were named as desirable, non-pharmalogical therapies that could be tried for pain in lieu of narcotic opioids. "The use of the word ‘preference’ suggests prioritization,” he comments, “This alone suggests a radical transformation from current practice.”

But when the CDC published the final version a few months later, the specific complementary and alternative therapies mentions were gone. The list now reads: “Exercise, aquatic, aerobic, psychological, cognitive behavioral therapy, and bio-psycho-social interventions."

With more Americans living with pain than diabetes, heart disease, and cancer combined (according to the American Academy of Pain Medicine), pain management in a cost-effective, consumer-friendly way is critical. And this is only made more relevant by the fact that many people are not getting the relief they seek from their conventional allopathic physicians.

Sources:

ACP. American College of Physicians issues guideline for treating nonradicular low back pain. American College of Physicians. Feb 2017. https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 Recommendations and Reports. March 2016. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.

Quseem A., MD, PhD, MHA, Wilt T., MD, MPH, McLean, R, MD, Forciea, M, MD Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. Feb 2017. http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

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