The most effective treatments for lower back pain

At some stage of life, most of us will suffer back pain that interferes with our day-to-day and, at any one time, about 20 per cent of Australians are suffering chronically. Experts agree that chronic pain is treatable, but what treatment is the best?

Chronic back pain is treatable, but what works best? A new study set to find out. Credit:Getty

Traditionally, treatment and pain education have focused on the biomechanics of pain – on what is happening physically that might be causing it – and on the physical therapies and movement patterns that can help.

Increasingly however, pain experts understand that chronic pain is not just physical. Pain signals can keep firing long after the body has healed itself. Fear of moving in certain ways; work, family and financial stresses; as well as imagining deterioration inside the body or nerves being crushed only prolong and intensify pain and poor function.

Psychological distress is “very common” among those suffering chronic pain, says Professor Paulo Ferreira from the University of Sydney.

“Over 50 per cent of patients who suffer chronic back pain are also diagnosed with depression,” Ferreira says.

This reduces their chance of recovery and increases the likelihood they will use heavy medication and opioids to manage their pain.

For physiotherapist turned researcher Emma Ho, prescribing exercise alone fell short of treating the problem. “My question, as a therapist, was what to incorporate into my treatment or what to recommend to patients as adjunct therapies?”

The clinical guidelines are vague. They suggest exercise, pain education and, perhaps, a multidisciplinary treatment but don’t specify what kind.

“It’s really poorly stated,” says Ferreira, a physiotherapist and pain expert. “The implication is that clinicians and patients read that kind of information and go ‘OK what exactly can I do here?’”

So, in a study published in The BMJ today, Ho and Ferreira sought out what the most effective treatments for chronic back pain are.

In the systematic review, they analysed 97 randomised controlled trials involving 13,136 participants and 17 different treatment approaches.

Specifically, the researchers looked at the short and longer-term outcomes for pain intensity, fear avoidance and physical function, comparing physiotherapy alone with physiotherapy and an adjunctive therapy like mindfulness, cognitive behaviour therapy (CBT), counselling, pain education programs or behavioural therapy.

The results varied depending on the outcome and time-frame they were looking at.

For instance, two months after treatment, CBT, pain education or behavioural therapy alongside physiotherapy (mainly in the form of structured exercise programs) were all effective for pain intensity. But, in the long-term, with physiotherapy, behavioural therapy, which includes muscle relaxation techniques and graded exposure to an activity where movement is broken down into parts, was the most effective long-term treatment for pain intensity.

For fear avoidance and physical function, CBT and pain education with physiotherapy worked in the short-term, however, pain education programs alongside physiotherapy had the best results long-term.

These approaches, when compared with physiotherapy care alone were as much as 20 per cent more effective 12 months after treatment.

“What we try to focus on now with pain education is helping people reconceptualise what pain is,” Ho explains. “Pain is a process that is driven by things that happen in your brain, but it can also be affected by your body structures. But it’s understanding that what proliferates it is not necessarily [structural]. Different processes in the brain can give you a heightened reaction to pain when the stimulus is not there.”

While Ferriera and Ho would like to see the guidelines updated to provide more specific recommendations, the “whole idea” is to inform patients, so they can have conversations with their GP or physiotherapist.

“Patients should not come to consultations with a passive attitude of just receiving whatever people tell them because unfortunately people still receive the wrong care for chronic back pain,” Ferreira says. “Clinicians prescribe anti-inflammatories or paracetamol. We need to educate patients and clinicians about options and more effective ways of managing pain.”

He says some physiotherapists and GPs are trained in psychological techniques for chronic back pain: “Online resources include Mood Gym.”

And although there were differences in trial design and quality that may have affected the study results, Ho insists that the research shows that good help exists and people can find relief.

“We want people to have confidence in managing their condition … to help them live their life to its fullest capacity.”

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