Acetaminophen (Tylenol®) does not reduce acute low back pain, according to the American College of Physicians’ latest review of the benefits of noninvasive treatments for pain in the lumbar region of the spine. Instead, the ACP endorses the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin.

For chronic low back pain, however, the ACP found anew that the antidepressant duloxetine (Cymbalta®) can be beneficial. Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI), not to be confused with more common SSRI antidepressants that inhibit the reuptake of only serotonin, thus increasing the amount that is circulating in the nervous system.  

The ACP defines “acute” low back pain as lasting less than four weeks. “Subacute” low back pain lasts from four to 12 weeks; and “chronic” pain lasts more than 12 weeks.

The ACP, which is a national organization of internal-medicine physicians, last reviewed the clinical-trial study reports and other scientific evaluations of the effectiveness of noninvasive treatments for acute, subacute, and chronic low back pain in 2007. The ACP’s findings that Tylenol lacks benefit, while Cymbalta offers it, are its only major new findings, although the approach it employs in its recommendations clearly demonstrates a shift toward emphasizing nonpharmacologic therapies rather than medications.

The ACP uses the evidence it reviews to formulate noninvasive treatment guidance for clinicians with low-back-pain patients. It bases its recommendations on the effectiveness (efficacy), comparative effectiveness, and safety of such treatments, both pharmacologic (drugs) and nonpharmacologic (heat wraps, massage, acupuncture, etc.).

You may read about the ACP’s findings and its new clinical guidelines in the “Annals of Internal Medicine” at http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice. Access to the article is free.

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As one who suffers from, and daily manages, chronic low back pain and associated radicular symptoms, I was keen on reading the ACP’s latest findings on the effectiveness of noninvasive therapies (not surgery or steroid injections) for low back pain of different durations. I think people with acute/subacute pain will be disappointed to discover how many routine therapies this esteemed organization omitted from its review; in particular, it ignored physical therapy in the acute/subacute phase. I strongly support PT.  

The ACP also does not distinguish between low back pain with radicular symptoms, such as pain, numbness, and tingling in a leg, and low back pain without such symptoms. Radiculopathy occurs when compression of a nerve in the spinal lumbar region, which causes back pain, also causes sensations to run along the course of the nerve into the leg.

Sciatica, which is pain that radiates along the sciatic nerve down the back of the thigh and sometimes into the calf and foot, is the most common type of radicular pain. I have numbness that runs along a nerve in my left inner thigh and inner calf, down to the sole of my foot. This numbness and tingling (known as paresthesia) can flare up and hurt me more than my back pain.

I keep my back pain in check with ibuprofen, regular exercise, and heat applied to the area, but my leg numbness, although it sometimes lessens, never goes away.

Of some interest to me is the ACP’s report that the nonpharmacologic interventions shown to be the most effective for improving pain and function in patients with acute/subacute low back pain are superficial heat and massage. Heat and massage provide more relief than acupuncture or spinal manipulation. This was my experience when I was coping with acute pain. Sadly, I did exactly what the ACP is trying to prevent with its guidance: I spent a lot of money on essentially worthless healthcare.

Low back pain is associated with exorbitant costs, both direct, in terms of treatment costs, and indirect, in the form of missed work and reduced productivity. The ACP advises clinicians to inform their patients with acute or subacute low back pain that they should remain as active as is tolerable and avoid costly tests (including an MRI, although the ACP doesn’t say so specifically) and treatments, such as epidural injections.

“Clinicians should reassure [such] patients,” it writes, “that acute or subacute low back pain usually improves over time regardless of treatment, and should avoid prescribing costly and potentially harmful treatments.” The body will heal on its own.

The ACP delivers a similar message about patients with chronic low back pain: Clinicians should select therapies that have the “fewest harms and lowest costs.” In particular, it advises clinicians to avoid prescribing long-term opioids.

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Although I suspect the ACP’s three recommendations about noninvasive treatment of low back pain are of limited value to physicians—in the same “Annals” issue, a physician editorial writer from the Massachusetts General Hospital calls them “simplified”—you may find them informative. They are:

Recommendation 1: “Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)”

Recommendation 2: “For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operate therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)”

Recommendation 3: “In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)”

Tramadol is an opiate painkiller. Contrary to the ACP’s guidance, I used oxycodone and hydrocodone, in combination with acetaminophen, when I had acute back pain, but only occasionally. I had no desire to take a narcotic. I have since found duloxetine to be helpful in relieving back pain. (The ACP found no evidence that SSRIs and tricyclic antidepressants are similarly efficacious.)

Although the ACP touts nonpharmacologic therapies, such as tai chi, yoga, meditation, or electrical nerve or muscle stimulations, among many other alternative practices, evidence of the benefits of any therapy other than heat and massage is very scant.

Deemphasizing opiate medications “makes sense,” writes Dr. Steve J. Atlas of the Mass General in an editorial that follows the ACP’s report in “Annals,” “[but] this approach is based more on the lack of evidence for long-term benefits and the growing perception about the risks of opioid use than on new evidence. The new recommendations do not address how to compare these treatments with invasive procedures that often are considered for patients with chronic low back pain.”

Ann, 4/11/17