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Back Pain Research Review
Back Pain Treatment Options
There are many different methods to treat back and neck pain. For both the caregiver and the person with pain it is important to know which methods have been shown with some scientific reliability can help and which methods have not been shown by scientific studies to have beneficial effect.
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Most methods have not been adequately studied scientifically in terms of patient outcomes to reach a conclusion about their effectiveness or lack of. This review presents what we know and what we do not know about the effects of different treatment methods, based on comparative studies found in the international scientific literature.
The Scientific Literature
Many of the studies available present only descriptions, perspectives, and opinions about the causes of the problem and discuss what can be done by way of cure, relief, and rehabilitation. Others present data from comparative studies on the outcomes of different treatment methods.
This review selected around 2000 studies which were found to present "relatively" strong scientific evidence on different issues concerning back pain. In most of chapters on treatment methods, the studies selected were limited to randomized controlled trials – ie, studies where patients were randomly allocated to different types of treatment to analyze whether the treatment had effects, and if so, which treatment yielded the best results. This methodology is the most reliable for assessing the outcome of treatment, even if it is not completely objective and may somewhat limit the conclusions. All studies that use this methodology are, however, not equally strong scientifically. Therefore, each study was graded according to the strength of the scientific evidence.
This was done as objectively as possible with the help of different protocols for grading the quality of the scientific assessments. However, in all chapters it was not possible to follow exactly the same procedure to grade the evidence of studies. As a rule, however, the studies were classified into groups that reflect: A) strong scientific evidence, B) moderate evidence, C) limited evidence, and D) no scientific evidence. Studies classified into group A) offer strong scientific evidence that a particular treatment has good effects or strong scientific evidence that a particular treatment is shown to be ineffective by randomized controlled trials and has no positive effects on a patient’s back problems.
At lower levels of confidence; groups B) and C), there is moderate or limited evidence is available to show the effectiveness or ineffectiveness of a particular treatment. To qualify for a moderate evidence rating only one controlled study or several low quality studies were necessary. Placement in these groups are indication that additional controlled study is advisable, particularly where positive or negative effects were found. Finally, placement in group D) means that no studies are available that are of adequate scientific quality to draw any conclusions from.. A summary of the results from the literature search is presented below.
Diagnosing Pain in the Neck and Low Back
Thorough, systematic medical, psychological histories and physical examination are a good foundation for diagnosing back pain according to many studies reflecting moderate evidence (B). Furthermore, many studies show that the caregiver’s involvement and ability to listen to the patient’s concerns – not only about pain and its localization but also about the consequences of pain and how it is dealt with – are essential to good diagnosis. Along with the medical history and physical examination, listening and talking allow the patient and caregiver to reach agreement on the best treatment. In most cases, this is a sufficient basis for developing a treatment strategy. It is also sufficient for identifying the few cases that must be referred for further investigation when a specific cause or serious disease may be responsible for the pain. If pain persists for 3 to 4 weeks, further investigation should be carried out using one of the validated questionnaires which are available, and which can identify other relevant problems, eg, in the work environment or the psychosocial situation in general (B).
Basic x-ray examination seldom provides guidance in diagnoses, except in cases where specific trauma or serious disease is present or suspected. As a rule, computed tomography (CT) and magnetic resonance imaging (MRI) studies do not identify where pain is located, again, except in patients where specific disease is suspected. A herniated disc pressing on a nerve root can cause severe sciatica. This condition can be visualized and confirmed by computed tomography or magnetic resonance imaging. The advantage of CT examination is that the procedure is noninvasive, and MRI examination does not involve a radiation risk. However, false positive findings are a risk associated with these types of studies. This risk is substantial, both regarding herniated discs and changes in discs resulting from aging or narrowing of the spinal and root canals, which appear in approximately 40% to 50% of symptom-free individuals.
Only limited evidence is available for many other diagnostic methods and their benefits (C). This applies to measurement of range of motion, muscle strength and condition, facet joint or nerve root blockades, spectrometry, discography, electromyography or neurophysiology studies, and radiographic measurement of segmental movements and various spinal diameters.
Moderate evidence (B) suggests that thermography and ultrasound studies do not contribute information toward establishing a diagnosis.
Conservative Treatment of Acute and Chronic Low Back Pain
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