Backache: its Evolution and Conservative Treatment

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References: 1. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. PMID: 2. PLoS One. PMID: 3. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. PMID: 4. Prasad V, Berger VW. Mayo Clin Proc. PMID: 5. Clin Ther. PMID: Braillon and Dr. Marcus questioning the efficacy of acupuncture. Although not all trials showed benefit 1 , acupuncture versus sham needles showed a small beneficial effect on pain, with no evidence of an effect on function in acute low back pain and improvement in both pain an function in chronic low back pain; similar findings were shown even when compared to NSAIDs.

However, we agree with the commenters that sustained benefit has not been demonstrated with acupuncture. We agree with Dr. Braillon regarding evidence of benefit with the use of cognitive behavioral therapy, and we recommend CBT in our guideline. We concur with Mr. Collen that there is both observational and meta-analytic evidence that suggests that NSAIDs may increase CV risk; however, as our review process is focused specifically on the setting of low back pain, we did not conduct independent evidence searches for the side effects of medications outside of the trials.

This is an admitted limitation of our process and one that we will need to consider in future reviews. Collen also notes that psychosocial support is essential to throughout the recovery process and it likely might be the case, but the evidence review did not identify any such studies to support the recommendations.

Guideline Focus and Target Population

Vucina notes that low back pain has heterogeneous causes, and that treatment may vary. We agree this is likely, but rarely addressed by current trials; further, there is no agreement on clear methods to define the source of low back pain, as symptoms and imaging findings are rarely determinative.

While we concur that the array of treatment options and the lack of head-to-head comparisons of these options makes choices difficult for physicians and patients, we would also comment that low back pain is so ubiquitous that training enough PSPs to care for back pain would be an undertaking of massive proportion. Ideally the options laid out in our guideline 2 , along with the fact that most back pain is self-limited, would suffice for many patients, and rare referral would occur for more refractory cases. We appreciate the updated review conducted by Drs.

Le and Badgett. Given their findings, we would agree that tramadol would likely not have been recommended as a treatment option for chronic low back pain. Systemic pharmacologic therapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine.

Reward Yourself

Brookdale Dept. We were pleased to see the ACP guideline on noninvasive treatments for low back pain in the April 4th, issue, however we were surprised there were no caveats on treatment of older adults nor discussion of the age of patients in the evidentiary trials. The stakes of improperly treated back pain may be high in older adults.

Common Causes of Back Pain

Each year back pain is experienced by nearly 17 million people 65 years and older. Older adults with chronic low back pain have more difficulty performing everyday tasks and more depressive symptoms. They are also at greater risk of adverse effects from some of the first line medications recommended in the guideline.

Our challenge as clinicians caring for these adults is to alleviate their pain without causing more harm, including greater functional decline. In the future, we hope that ACP will consider a focus in their guidelines that helps clinicians address the complexity of low back pain in aging adults.

Jeremy D.

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Physical Therapy 3 How does low back pain impact physical function in independent, well-functioning older adults? Pain Med. Pilotto, Alberto, Franceschi, Marilisa, et al.


The risk of upper gastrointestinal bleeding in elderly users of aspirin and other non-steroidal antiinflammatory drugs: The role of gastroprotective drugs. Alvarez, Carlos A. Association of skeletal muscle relaxers and antihistamines on mortality, hospitalizations, and emergency department visits in elderly patients: a nationwide retrospective cohort study. BMC Geriatrics Previous acupuncture recommendations are now being reconsidered by many prominent institutions. The Toronto Hospital for Sick Children has also recently removed references on their website that suggested the efficacy of acupuncture in managing specific chronic pain conditions.

The WHO has done the same, no longer suggesting that acupuncture is effective for low-back pain and sciatica.

Backache: its Evolution and Conservative Treatment - Semantic Scholar

A review by the Friends of Science in Medicine association describing a lack of evidence of a therapeutic effect has been endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Such claims are generally based on small and probably unmeaningful effects taken selectively from the total evidence. Many of these entities specifically mention the ACP as lending credence to their claims, sometimes somewhat out of context.

I hope that you will reconsider your recommendation of a practice that is simply not supported by the majority of the research evidence that exists to date. Patients with complex conditions, including low-back pain, deserve accurate and realistic information regarding their treatment options, especially from such trusted and reputable sources as the ACP.

This comment is condensed from a longer open letter to the ACP that can be accessed, with further sourcing, via the reference below. MacGregor, A. Acupuncture for back pain: an open letter by a Canadian therapist. Treatment failure is a treatment issue, not a patient issue. The guideline is generally useful and helpful; however, I wish the third recommendation had been phrase just a little differently. The language we use to talk about whether and how our treatment has, or has not, helped our patient can shape our thinking.

Chronic Low Back Pain

Many authors have written about how the language we use can change the way we think. No one has written more trenchantly about this issue than George Orwell in his novel, , and in his essay, 'Politics and the English Language. Right in the middle is the phrase, "in patients who have failed the aforementioned treatments. The treatment has failed to help the patient.

We should not blame the patient for "failing" to improve, but rather accept our responsibility for recommending, with good reason, a treatment which was intended to be helpful, but which has failed to improve our patient's condition. Our desire to linguistically offload responsibility to the patient is understandable, but pernicious, especially when we are considering whether to prescribe opioids for chronic pain. While the evidence for benefit is weak, there are some patients who do well with them, provided that we prescribe opioids responsibly, and continue to provide other forms of treatment and support for chronic back pain.

If we label our patients as "failures," will we be less likely to consider prescribing opioids for them?


I suspect that this habit of thinking of the patient having failed the treatment makes us less willing to consider opioids, even when other evidence might suggest a benefit. We should accept responsibility for our treatment failures, by clearly and consistently labeling the treatment, rather than the patient, as the failure. Published at www. Results provided by:. Sign In Set Up Account. You will be directed to acponline. Open Athens Shibboleth Log In. Subscribe to Annals of Internal Medicine.

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