Almost everyone gets back pain. It’s as inevitable as paying taxes and death. But at least you can take painkillers, right? Except that the American College of Physicians (ACP) has announced that drugs should no longer be the first line of treatment. Instead of reaching for paracetamol or ibuprofen, you should try treatment such as heat (superficial), massage or acupuncture. Codeine (with paracetamol) and the occasional diazepam are particularly frowned upon because they carry the risk of addiction.
Of course, times change: I remember patients with back pain regularly arriving by ambulance to be strapped on to beds with traction devices. Antidepressant drugs, just as antiquated a treatment, are now rejected by the ACP as being no more effective than placebos.
The solution
Acute back pain usually lasts less than four weeks – if it persists for more than 12, then it becomes chronic. Up to 30% of us will have low back pain a year after having an initial attack. What the ACP stresses is that most people with back pain get better, regardless of treatment. Doctors should therefore avoid any tests and treatments that could cause harm.
The ACP’s recommendations are based on a thorough review of the evidence – but the research is often poor. Massage and acupuncture are recommended based on “low-quality evidence” and the health watchdog Nice takes the opposite view, stating: “Do not offer acupuncture for managing low back pain.” Both Nice and the ACP suggest trying spinal manipulation, although Nice only recommends it as part of a treatment package that includes of exercise and psychological therapy. The research is weak on whether heat helps, but anyone with back pain can probably testify to the benefit of a hot water bottle.
If nothing else works – and the passing of time has the most evidence going for it – the ACP suggests non-steroidal anti-inflammatories such as ibuprofen. You could also try a Smartie: earlier this month, research showed ibuprofen was not much better than a placebo for relieving back pain. Ibuprofen is also, unfortunately, good at causing gastric problems such as inflammation of the stomach and ulcers. Paracetamol is also no better than placebo for helping back pain.
Nice says it is reasonable to try weak opioids for acute pain if ibuprofen does not work or is too risky. For chronic pain, the ACP recommends exercise, acupuncture (again) and mindfulness, as well as tai chi and yoga. For sciatica, where a nerve root is compressed in the spine, there is little evidence that any interventions help a lot.
Nice stresses the importance of exercise, psychological therapies and for people to continue with normal activities. Anyone with chronic back pain will know there is no magic bullet. These latest recommendations focus on not making things worse.
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