Okay so you’ve been doing some self-care exercises and educating yourself about LBP, now you’ve decided to get some treatment – but which type do you choose?
No specific treatment
By definition we do not know the exact cause of (non-specific) LBP, which means it doesn’t have a specific treatment. Instead, the management is focused on addressing the signs and symptoms of this condition (mainly pain and disability).1 As I’ve already mentioned, some experts argue that LBP consists of many different conditions. This may explain why it is still so hard to treat,2 and why there is so much individual variation with treatment effects. It is not uncommon for two people visiting the same health professional to experience vastly different results. On the bright side, at least major treatment options are safe, with serious adverse events occurring rarely.3
What about my family doctor?
Traditionally, your family doctor (physician) was the first point of contact for virtually all non-urgent health concerns. They assist in the treatment and management of your health condition by monitoring your progress and acting as an intermediary with other health professionals. In the case of LBP, they will most likely diagnose you (non-specific LBP) before offering reassurance and advice (self-care). They can also offer medical prescriptions (pharmaceutical drugs) and refer you for diagnostic or medical tests (if red flags are present), as well as to see other health professionals. Usually if they deem it beneficial they will just recommend you visit an appropriate health professional, such as a spinal care specialist (physiotherapist or chiropractor). And while they will advise you of your treatment options, ultimately you decide where you’d like to go. Therefore, family doctors are a good starting point if you’re feeling uncertain (for example, if the episode is your first, or quite severe). However, if you’ve already experienced a LBP episode, or had experience with other health professions already, you may not feel the need to visit your family doctor. Since mostly referrals aren’t necessary, more and more people are heading directly to these other health professionals for treatment. This recent trend not only includes ‘allied health’ professions but also various forms of complementary medicine such as massage and acupuncture.
Personal preference or latest evidence?
Everyone is unique and therefore personal preference is important when it comes to choosing your LBP treatment. Maybe you hate needles, in which case I’d be foolish to recommend you acupuncture! However, as much as I recognise personal preference counts, I also believe that if you want to make the most informed decision, you also need to consider the latest evidence. In this way, clinical practice guidelines help primary healthcare professionals (e.g. family doctors, physiotherapists) and their patients alike. These evidence-based documents serve as broad instructions for clinicians to provide best practice for LBP. This includes objectively outlining the latest evidence for and against various treatment modalities/techniques. Despite them being produced in various countries (with different regulations and legislations etc.), the fact that they are evidence-based means the core recommendations of these guidelines are usually the same.4
Introducing three clinical practice guidelines
Clinical practice guidelines only remain relevant for as long as the evidence they’re based on is up-to-date. Therefore, the recommendations below are based on the three most current guidelines at the time of writing:
• Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians – USA (2017)3
• NICE Guideline on Low Back Pain and Sciatica – United Kingdom (2016)5
• Evidence-Informed Primary Care Management of Low Back Pain – Canada (2015 – minor update in 2017)6
[NB: For simplicity, hereafter I’ll refer to these individually as either the UK, US or Canadian guidelines.]
Core recommendations from the guidelines
All of these guidelines strongly advocate self-care (staying active) and education as the ‘first-line’ approach in managing LBP (previously covered in ‘What can I do for pain relief?’.) The remaining treatments can therefore be considered part of the second-line approach. Another point of agreement between these guidelines is that they all place more emphasis on non-pharmacological interventions.7 In other words, pharmaceutical drugs are recommended only once non-pharmacological interventions have been tried (and then only for the shortest period possible). Another recommendation made across these guidelines was multidisciplinary treatment programmes whereby more than one type of treatment are used in combination. This was especially true in chronic LBP cases, whereby exercise and psychological approaches were recommended to be used together. Other core recommendations include the use of heat (packs) and advice to return to work early.
Summary of clinical practice guidelines – main treatment options:
‘So I’ve Got LBP, What Now’ primarily focuses on acute and/or episodic LBP (‘flare-ups’) rather than truly persistent (chronic) LBP – which will be covered at a later stage. However, I have included some chronic treatment options as a means of highlighting the key differences. Also worth mentioning is the fact that unlike its counterparts, the UK guideline doesn’t differentiate LBP according to the duration of symptoms (acute/subacute/chronic).
Below are the major treatment options for LBP with supporting recommendations from the above clinical practice guidelines:
1. Manual therapy
In the most basic sense, manual therapy is ‘hands-on’ treatment. Common examples of health professionals that perform manual therapy include:
• Osteopathic manual therapists (simply called ‘osteopaths’ outside of the US and Canada)
• Osteopathic physicians*
• Massage therapists
• Traditional Chinese Medicine (TCM) practitioners
* Osteopathic physicians are medical doctors who also have training in manual therapy techniques although not all of these physicians utilise these skills in their professional practice.
Manual therapy is a vastly popular treatment method for LBP. It consists of many different types of ‘techniques’, two of which are massage and spinal manipulation (see below). And while many of the above health professions use techniques in common, their philosophical differences mean that they usually specialise and develop their own versions. To make matters more confusing, these differences exist not only between professions, but also within them.6 This makes it more difficult to recommend treatment modalities based on specific treatment methods.
1 a) Massage
Massage is an extremely broad term used to describe manipulation of the body’s ‘soft tissues’ (i.e. muscles, tendons, ligaments, and fascia/connective tissue). It’s perhaps the most widely practiced manual (therapy) technique amongst manual therapists. When I first started learning this skill, my instructor liked to joke that it was the second oldest profession in the world behind…well, something else! 😉 Jokes aside, I think there’s a reason it’s been around for so long…it’s awesome! Unfortunately, just because it feels great, doesn’t make it effective for treating LBP.
Acute and subacute
• The Canadian guideline only recommends massage as an adjunct to other treatments (inconclusive evidence).
• The American version stated that massage made a small to moderate improvement in both pain and function (low-quality evidence).
• The Canadian guideline recommends massage for chronic LBP but only as part of a broader active rehabilitation program (key word being active).
• The UK version recommends it as a treatment package with exercise and possibly psychological therapy.
1 b) Spinal manipulative therapy
Many of the above professions are also trained in their own version of spinal manipulation, which involves precisely and rapidly directed manual impulses (or thrusts) to spinal joints.8 This type of technique is perhaps best associated with the audible ‘crack’ or ‘pop’ it often makes.9
Acute and subacute
• The Canadian guideline recommends spinal manipulation for patients who are not improving.
• There is low-quality evidence that spinal manipulation improves function by a small amount compared with no treatment, although it was not significantly different when compared with sham (‘fake’) manipulation (US guideline).
• The Canadian guideline recommends against spinal manipulation for chronic LBP.
• Low quality evidence found that spinal manipulation had a small effect on decreasing pain (US guideline).
• Like massage, spinal manipulation is recommended as an adjunct to exercise and possibly psychological therapy (UK guideline).
Most people have heard of this form of complementary medicine which involves sticking fine needles into the body. Technically it is one component of Traditional Chinese Medicine (TCM).
Acute and subacute
• The Canadian guideline states that there is inconclusive evidence to recommend acupuncture.
• Low quality evidence found that acupuncture decreases pain by a small amount (US guideline).
• The Canadian guideline recommends it as a short-term therapy as part of a broader active rehabilitation program.
• The US version recommends it based on moderate-quality evidence that it decreased pain and function by a moderate amount compared with no acupuncture. It also stated that there is low-quality evidence it improved pain (moderate effect) but not function when compared with sham acupuncture.
• The most recent UK guideline recommends against using acupuncture for treating LBP (insufficient supporting evidence).
3. Psychological therapies
Psychological therapies are first-line treatments for chronic LBP although are less commonly used for symptoms of shorter duration. The more yellow flags a person presents with, the more important these will be. CBT is possibly the most recognised form of psychological therapy which is commonly used in chronic pain management. Other examples include things like progressive relaxation and mindfulness-based meditation.
• Both the US and Canadian guidelines recommend various psychological therapies in the treatment of chronic LBP based mainly on low-quality evidence.
• Progressive relaxation and CBT both had a moderate effect on pain, whereas the former also had a moderate effect on function (US guideline).
• The Canadian version recommends group or individual CBT programs for chronic pain management.
• The UK guideline recommends CBT be used as an adjunctive treatment to exercise and manual therapy. It states that the importance of this recommendation increases when a person presents with psychosocial obstacles (yellow flags) such as fear avoidance behaviours and catastrophising, or when previous treatments have been ineffective.
Exercise as a therapy is recommended in some form by all of these guidelines, especially for chronic LBP where it is a first-line treatment option. In particular the UK guideline has it as a core component of its non-pharmacological options (two of these options are recommended as adjuncts to exercise).
The UK and Canadian guidelines could not specify any approach which is more effective (and therefore recommended several varieties). This is in line with current evidence which suggests no one type of exercise is superior in the treatment of chronic LBP.10,11 However, the US version outlined several components associated with better pain outcomes. These included individually designed programs, supervised home exercise, and group exercise. Furthermore, it stated that the most effective treatments included stretching and strength training. None of the guidelines could provide any detailed recommendations concerning the duration and frequency of the recommended exercise types.6
Acute and subacute
• In addition to general exercise (staying active), the Canadian guideline recommends ‘therapeutic exercise’ for treating subacute and chronic LBP. This includes various types of exercises that are prescribed specifically for an individual’s condition by a suitably qualified health professional (e.g. physiotherapist). Moreover, the guideline states that the focus of these exercises should be on increasing function while de-emphasising pain, and that anyone whose pain is worsened through physical activity should be referred to a spinal care specialist.
• The UK guideline recommends people with a specific episode (flare-up) of LBP try a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches).
• The Canadian version specified two types of yoga (Viniyoga and Iyengar) which have been found to be particularly useful in treating chronic LBP. It also recommended the use of unsupervised walking and group exercise programs.
• The US guideline recommended exercise for chronic LBP on the basis that it improved pain and function by a small amount (moderate-quality evidence). Specific forms of exercise were also recommended including motor control exercise (MCE), tai chi, and yoga. MCE and tai chi both had moderate and small effects on pain and function respectively. Yoga improved pain and function by a moderate amount compared with standard care although this decreased to a small amount when compared with education.
• The UK guideline recommends exercise as a core component of its non-pharmacological interventions (manual and psychological therapies are only to be used in combination with exercise, including in multidisciplinary programmes).
5. Pharmacological therapy
All three guidelines agree that pharmacological therapy should only be considered once non-pharmacological options have been tried.
Acute and subacute
• The Canadian guideline is the only guideline to recommend acetaminophen (paracetamol) by itself for acute LBP.
• The UK version specifically advises against using acetaminophen alone for LBP. However, it does advocate using it in combination with weak opioids in specific cases of acute LBP (see ‘opioids’ section below).
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Acute, subacute and chronic
• All guidelines recommend oral NSAIDs for acute AND chronic LBP (first-line pharmacological option).
• The UK version cautions that these drugs should be taken at the lowest effective dose for the shortest period possible to minimise potential harm from side effects.
• The US guideline states that NSAIDs had a small reduction in pain (moderate-quality evidence) and function (low-quality evidence).
• The only guideline that considered topical NSAIDs was the Canadian version which could neither recommend for or against these drugs (inconclusive evidence).
Skeletal muscle relaxants
Acute and subacute
• The Canadian and US guidelines recommended muscle relaxants for acute LBP.
• The Canadian guideline recommends a short course of these drugs either on their own, or in combination with NSAIDs, if acetaminophen or NSAIDs haven’t reduced pain.
• The US version suggests that the choice between muscle relaxants and NSAIDs should be made based on the individual’s preference and also their pharmacological risk profile (vulnerability to side-effects).
• Muscle relaxants are recommended in selected patients with chronic LBP for relief of muscle spasm and pain (Canadian guideline).
The most controversial class of pharmaceutical drugs due to their high risk of harm (dependency/abuse). Consequently, all guidelines are cautious in their recommendation of these drugs.
Acute and subacute
• The Canadian and UK guidelines advise that weak opioids (often in combination with acetaminophen) can be considered for acute LBP under specific circumstances. Specifically, if a person is unable to take (or tolerate) NSAIDs, or if acetaminophen and NSAIDs have been ineffective. The Canadian guideline also stipulates that it must be prescribed at a minimum dose for only a short period of time (usually less than 1-2 weeks).
• All guidelines caution against opioid use in chronic LBP management.
• According to the US guideline, opioids should only be considered for chronic LBP once all other therapies have failed (moderate-quality evidence). It found that opioids had a minor effect on short-term pain and function (moderate-quality evidence).
6. Interventional therapies and surgery
NB: These interventions are only to be considered as a last resort. Indeed, they have an extremely limited role, if any, in LBP management.7
Acute and subacute
Invasive treatments are rarely indicated for acute or subacute LBP.
On rare occasions these interventions may be considered in chronic LBP however many of them are still controversial.
• The UK guideline recommends two interventional therapies including radiofrequency denervation and epidural injections. Radiofrequency denervation is only indicated in people with chronic LBP who have had a positive response to medial branch block (a specific diagnostic procedure). Epidural injections of a local anaesthetic and steroid are advised in people with acute and severe sciatica (leg pain).
• The only surgical treatment option recommended by the UK guideline was spinal decompression. This intervention was recommended for people with sciatica which has not had pain or functional improvements after non-surgical treatment, AND, is explainable using medical imaging.
• According to the Canadian guideline patients should be referred for a surgical consult only after they have participated in a combined physical and psychological treatment program for 6 months, and they still have severe LBP. It does not comment on any specific surgical interventions.
Let’s wrap this up
The above list of treatment options is by no means an exhaustive list. Instead it represents some of the most common and successful ‘second-line’ options (at least in terms of research). And yet, clearly there aren’t any that stand head and shoulders above the rest. Mostly these treatments have relatively weak effects in terms of improving pain and function in LBP.
What does this mean for you? It’s definitely not doom and gloom! For one, it means that to a large extent your choice can be governed by your personal preference, supplemented with the evidence above. If you like stretching, try yoga! If you like massage, get some kind of manual therapy. Provided you loosely follow the guidelines above, you don’t have to worry about going ‘too wrong’. You may need to experiment to find the perfect one though, since there are possibly hundreds of variations of the above treatment modalities. Even within an individual one, for example physiotherapy, there are literally dozens of practicing styles. So, find something above that interests you, talk to your friends and family, do some Googling, and maybe even toss some coins. Use what’s worked for you in the past to guide your current decision. Remember, as more evidence is brought to light these guidelines (and their recommendations) will undoubtedly change. And even if your treatment is less than impressive in the eyes of science, individual results vary greatly so it may yet have spectacular results for you. Good luck!
• Without a specific cause for LBP, we cannot have a specific treatment. Instead, management is focused on treating the signs and symptoms of this condition (mainly pain and disability).
• Visiting your family doctor is a good place to start if you’re uncertain about your LBP (e.g. first or severe episode).
• Often people head directly to another health professional (e.g. a manual therapist) for treatment.
• Use your personal preference supplemented with current evidence to choose the best treatment option for you.
• Clinical practice guidelines are evidence-based documents which help primary healthcare professionals and their patients by encouraging best practice for LBP.
• Manual therapy is essentially ‘hands-on’ treatment and is practiced by many health professionals including physiotherapists, chiropractors, osteopaths, massage therapists etc.
• Massage and spinal manipulation are two types of manual (therapy) techniques.
• Massage is an extremely broad term used to describe manipulation of the body’s ‘soft tissues’ (i.e. muscles, tendons, ligaments, and fascia/connective tissue).
• Spinal manipulation involves a precisely and rapidly directed manual impulse (or thrust) to a spinal joint. This type of technique is widely recognised for the ‘crack’ or ‘pop’ it often makes.
• First-line treatment options for acute/subacute LBP include patient education and advice to stay active.
• Second-line treatment options for acute/subacute LBP include manual therapy – e.g. acupuncture/chiropractic (weak evidence), acupuncture (inconclusive evidence), psychological therapies (low quality evidence – more for chronic LBP), exercise therapy (moderate-quality evidence), and pharmaceutical drugs (low to moderate-quality evidence).
• Interventional therapies and surgery (invasive procedures) have an extremely limited role, if any, in LBP management.
• Even the most successful LBP treatments have relatively weak effects in terms of improving pain and function, therefore, choose one you like!
• As new evidence comes to light new recommendations (guidelines) will be produced!
1. Maher C, Underwood M, Buchbinder R. Non-specific low back pain (Seminar). www.thelancet.com. 2017;389. doi:10.1016/S0140-6736(16)30970-9.
2. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007;16(10):1539-1550. doi:10.1007/s00586-007-0391-1.
3. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514. doi:10.7326/M16-2367.
4. O’Connell NE, Cook CE, Wand BM, Ward SP. Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines. Best Pract Res Clin Rheumatol. 2016;30(6):968-980. doi:10.1016/j.berh.2017.05.001.
5. National Guideline Centre (UK) “Low back pain and sciatica in over 16s: assessment and management.” 2016. https://www.nice.org.uk/guidance/ng59. Accessed May 29, 2018.
6. Toward Optimized Practice (TOP) Low Back Pain Working Group. Evidence-informed primary care management of low back pain: clinical practice guideline. 2017. http://www.topalbertadoctors.org/cpgs/885801.
7. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet (London, England). 2018. doi:10.1016/S0140-6736(18)30489-6.
8. Spinal Manipulation – Physiopedia. https://www.physio-pedia.com/Spinal_Manipulation#cite_note-Rubinstein-1. Accessed June 15, 2018.
9. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal Manipulative Therapy for Chronic Low-Back Pain. Spine (Phila Pa 1976). 2011;36(13):E825-E846. doi:10.1097/BRS.0b013e3182197fe1.
10. Unsgaard-Tøndel M, Fladmark AM, Salvesen Ø, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Phys Ther. 2010;90(10):1426-1440. doi:10.2522/ptj.20090421.
11. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. 2017. doi:10.1002/msc.1191.