SIB# 417 - Mechanical Low Back Pain
The Study: Mechanical Low Back Pain
The Facts:
a. “Low back pain is usually nonspecific or mechanical.”
b. “The diagnosis of mechanical low back pain should be made when systemic disease and referred pain have been ruled out, and no red flags have been identified.”
b. Mechanical low back pain can come from ‘the spine, intervertebral disks, or surrounding soft tissues.”
c. Strong evidence exists for care using yoga in the short term as well as moderate evidence for yoga in the long term when used to treat chronic low back pain.
c. Treatments for low back pain that were deemed to have moderate evidence of support: opioids, nonsteroidal anti-inflammatory medication, “and topiramate in the short-term treatment of nonspecific chronic low back pain.”
d. Manipulative therapy of the spine has shown mixed results for both acute and chronic low back pain.
e. However, they also note in Table 4 treatment options for mechanical low back pain. “Osteopathic manipulative treatment: Shown to be effective at reducing acute and chronic mechanical low back pain in a systematic review and meta-analysis.”
f. McKenzie exercise use may result in less recurrence.
g. Common causes of mechanical low back pain include overuse injuries and repeated traumas.
h. If you have one episode of “activity-limiting low back pain” you are likely to have another one.
i. The authors note: “Relatively few patients with mechanical low back pain will benefit from surgery.”
j. Here are some of their key recommendations for practice which had evidence ratings of A; non-steroidal drugs, Topamax and opioids were found to be better than placebo for short term treatment of chronic low back pain that is non-specific. (Emphasis ours. Ed.)
k. Some key recommendations for practice with evidence ratings of B: Basically no initial imaging except when red flag indicators /concerns such as cauda equina, cancer, infection or fracture are present. McKenzie exercises may decrease the frequency of reoccurrence. Also intensive patient education in cases of nonspecific pain in which they note that: “a discussion of the often benign nature of acute low back pain is effective in patients with nonspecific pain.”
l. Evidence ratings were defined by the authors as follows, “A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence.”
Take Home:
Depending on the evidence rating: Opioids and some other drugs are better than placebo. Imaging should be quite limited at the beginning of the case. McKenzie exercises may decrease reoccurrences.
Reviewer's Comments: First this is a subject that is very complex and I applaud the authors for taking on this task. Although I have some concerns that are too lengthy to explain here, this is their evaluation and they have 48 references (not a huge amount for this type of article) upon which they based their opinion. You have to wonder what the outcome would be if you compared some of these interventions to “watchful waiting”. “Watchful waiting” wouldn’t appear to have the same risk of addiction as does opioids. And in that vein, recall that the authors stated, “a discussion of the often benign nature of acute low back pain is effective in patients with nonspecific pain.”
The basis of science is to let everyone present their evidence and then join in the discussion. This article is far too complex for us to cover everything it contains but because it comes to conclusions which are different from what many in our profession might support, we recommend you read the article to get a full understanding and make your own decisions.
PS. You’d think that since this is a discussion of mechanical low back pain then maybe trying to change the biomechanics of the spine might be a logical thought, but apparently not.
Reviewer: Roger Coleman DC
Editor: Mark R. Payne DC
Reference: Joshua Scott Will, David C Bury, John A Miller. Mechanical Low Back Pain. Am Fam Physician. 2018 Oct 1;98(7):421-428.
Link to Abstract: https://pubmed.ncbi.nlm.nih.gov/30252425/
Link to Article: As the time of this posting, the AAFP website which will host the full text article was unavailable but should be back up on Mon. Aug. 17. Interested readers may link back to the abstract and will find the website link on the right side of the page.