Guidelines for lower back pain?

Scott Alexander wonders why we don’t have “guideline” algorithms for more difficult-to-treat problems, in addition to depression. Meanwhile, elsewhere on the internet, the first steps toward establishing something like that for back pain.

That piece cites several journal articles, including lower back pain in spaaace!, but the most important one is this literature review – gated, but free.

According to their handy chart, we need two sets of guidelines for lower back pain – one for acute low back pain, lasting less than six weeks, and another for persistent low back pain, lasting longer that twelve weeks. Pity those poor souls whose lower pain lasts between six and twelve weeks, for science knows nothing of their suffering!

For acute low back pain:
1. The first-line treatment is education and “advice to remain active.”
2. The second-line treatments could include superficial heat, spinal manipulation, massage, acupuncture, and non-steroidal anti-inflammatory drugs (e.g. ibuprofen.)
3. Opioids and skeletal muscle relaxants are recommended only for “limited use in selected patients.” Having seen someone in acute back pain who couldn’t get up off the ground until she got some opioids, I wouldn’t rule these out.
4. Paracetamol, systemic glucocorticoids (steroids), and epidural steroid injections are not recommended.
5. There is “insufficient evidence” for mindfulness therapy, yoga, SNRIs, anti-seizure medications, and surgery – though I’m not sure anyone actually wants surgery for back pain lasting less than six weeks.

For persistent low back pain:
1) Exercise therapy and cognitive-behavioral therapy are the souped-up versions of “advice to remain active” and “education”, and they are first-line therapies.
2) Actually, screw this list. Almost everything else remains the same, with some minor shuffling between “insufficient evidence” and “second-line treatment.”
3) Steroid injection go from “not recommended” to “limited use”, discectomy and laminectomy go from “insufficient evidence” to “second-line treatment”, and spinal fusion gets “role uncertain”, which is apparently different from “insufficient evidence” in some mysterious way.

Broadly, these recommendations echo those of McGill and Ingraham, especially the part about exercise and cognitive-behavioral therapy being the first-line treatments. There are minor differences in opinion about second-line treatments – Ingraham is adamant that acupuncture is no more effective than placebo, and that discectomies and laminectomies are almost never necessary, and he thinks the role of spinal fusion is quite “certain”-ly bad – but the emphasis on exercise and therapy is the same, as is the caution regarding currently-or-formerly popular invasive treatments like opioids, steroid injections, and surgery.

Back to the original pop-science article for the moment – the author’s own recommendations seem to be based largely on competitive rowers, who apparently injure their backs all the time, and almost always recover fully. She only cites one article about rowers, but it sounds like there’s more out there – and this is an interesting approach to health care research: studying not the public at large, but a sub-population that is subject to unusual and extreme experiences.

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