Back Pain Research Review

In 2000 the Swedish Council on Technology Assessment in Health Care (SBU) appointed an international project group of 13 people who were charged with reviewing the results from scientific studies published during the 1990 and earlier. The report contains 21 chapters, 2000 references, and covers 800 pages. Approximately 80% of the studies referenced have been published since a previous report in 1980. Today, approximately 25 000 studies on back and neck pain have been identified, whereof approximately 1000 are randomized and/or controlled studies.

The most surprising realization after studying this report is how little good science there is related the the causes and cures of back pain. Alot of science but little convincing evidence in most areas under study. Keep in mind No Evidience does not mean something is not the cause or is not effective as a treatment, It Does mean that there have not being adequately designed studies on the issue.

Pain is a signal that something is wrong. Regardless of its location, pain should be investigated to confirm or eliminate its association with a specific cause or serious disorder.

Although pain in the low back or neck affects most people at some time during their lives, it is seldom a sign of serious illness. In some people, the effects are more severe and more frequent, but most experience mild effects and only occasionally. Few experience constant, persistent pain.

To Date Research Has Been Of Little Help

Research seldom explains why or how pain in the low back or neck originates, or how long it will last, ie, whether it is acute and temporary or will remain a chronic problem. It can result from different, but perhaps associated, factors. The relationship of these factors often remains unknown. Although it is not always possible to cure back pain, treatment methods are available which can effectively relieve pain in most people.

Back Pain and Individual Factors

Numerous studies have analyzed whether factors related to the individual, eg, gender, age, body length, weight, anatomic changes in the spine, and smoking correlate in any way with back pain. The data currently available do not reveal any specific, individual risk factors for back pain.

Most studies find no differences in the risk for back pain, neither between men and women nor among individuals of different height, weight, etc.

One Distinguishing Characteristic

The only exception would be the occurrence herniated discs, resulting in sciatica in people aged 40 to 45 years old.

Working Conditions Contribute to Back and Neck Pain

Heavy physical labor and poor working environments are often cited as reasons for back pain. There is a clear correlation between reported low back problems and heavy lifting or working positions in which the back is bent or twisted repeatedly and over a longer period of time. This also true for work that involve long period of sitting on “shaky” vehicles such as forklifts, trucks, and tractors. As regards neck problems, studies have found a clear association between repetitive, monotonous work and fixed working positions.

Psychosocial Aspects of Back and Neck Pain

Many types of pain and their duration and intensity are associated with poor psychosocial conditions in private life and the workplace, including poor work satisfaction. This is particularly true for back and neck pain.

Pain in the neck or low back can influence functional capacity and cause worry, anxiety, and depression. It has been known for some time that mental/emotional states such as worry, anxiety, and depression. this, in turn, can amplify the perception of pain, but only recently have psychological factors been viewed as a link in the causal chain underlying the occurrence and persistence of neck and low back problems. There is well-documented scientific evidence that numerous psychological factors can influence the development and persistence of acute and chronic pain in the neck and low back. These problems occur since mental state, feelings, and behavior are partly dependent on factors such as work demands, time pressure, monotonous work, a low level of influence over the situation, poor social support, experienced pain, stress, worry, and anxiety.

Preventative Measures

Despite the insight on the important roles of these factors, research has contributed little by way of studies to assess preventive interventions against back pain. The studies which have been conducted in the field have focused primarily on rather narrowly defined preventive measures such as ergonomic methods, physical exercise, education on back anatomy, various supportive devices for the lumbar spine, and interventions to influence smoking, overweight, and certain psychosocial factors. The results of these studies are discouraging in the sense that most of the preventive measures studied are shown to be ineffective. The only exception is moderate, but regular physical training or exercise, where the results of several studies show good effects.

It seems likely that the preventative measures employed in most short term or narrowly focused studies were insufficient in themselves to overcome pervasive causal factors that are indicated in back and neck pain.

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. 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

Conservative treatment refers basically to all non-surgical treatment methods, excluding psychological treatment (discussed separately below). Conservative treatment methods include drugs, acupuncture, injections of various types, back exercises, back school, manual treatment, manipulation, physical methods, traction, corsets, TENS (transcutaneous electrical nerve stimulation), behavioral therapy, multidisciplinary treatment, biofeedback, rest, and activation. The appendix to this summary presents an overview of the effects of various treatment methods. Here, the only conclusions presented on conservative treatment methods are those supported by strong evidence.

For acute low back pain, there is strong evidence that:

continuing with normal activities results in faster recovery and
fewer chronic functional disorders,
anti-inflammatory and muscle relaxant drugs offer effective
pain relief for uncomplicated, acute, low back pain (however, these drugs have some side effects),
bed-rest is not effective treatment for acute low back pain, and exercises involving bending, traction, aerobics, and stretching do not effectively cure acute low back pain.

For chronic low back pain, there is strong evidence that: manual treatment/manipulation, back training, and multidisciplinary treatment are effective in relieving pain.

Intensive treatment at a health resort reduces pain in the short term for elderly patients (over 60 years of age) with chronic low back problems.

Conservative Treatment of Acute and Chronic Neck Pain

Conventional treatment methods that are normally used to treat neck pain are largely similar to those used to treat low back problems. The treatment methods reviewed in this report include drugs, physical training, manual treatment, massage, body exercises, muscle training, heat packs, ergonomic counseling, traction, acupuncture, TENS, electromagnetic treatment, magnet therapy, patient education, behavioral therapy, steroid injections, and treatment involving neck collars, infrared light, ultrasound, lasers, cooling spray, and stretching.

Only a few studies in this field are of high scientific quality. In summary, only moderate or limited evidence is available to show that any of the treatment methods are effective in treating acute or chronic neck pain. However, there is strong evidence to show that acupuncture is not an effective method in treating chronic neck pain (A).

Surgical Treatment

When assessing the results of surgical treatment, the importance of weighing the risks and benefits of intervention increases.

Low Back Pain

Surgery for low back pain usually involves treating herniated discs in patients with sciatica, reducing pressure on painful nerve roots, or treating degenerative disc disease (which is a common age-related syndrome) where surgery is used to reduce pressure and/or stabilize vertebrae through fusion. Numerous surgical methods are used to treat herniated discs, eg, with or without the help of lasers or microscopes, or through minimally invasive surgery. There is no scientific evidence to show that these surgical methods would yield better results or fewer serious complications than conventional surgery (D).

The reviewed studies reveal many methodological deficiencies, mainly the studies on surgery for degenerative disc disorders aimed at measuring outcomes (which were often based on rough estimates by either the surgeons themselves or by patients who underwent surgery).

There is limited evidence on the outcome of surgery for herniated discs, but there is strong, indirect evidence on its effectiveness. The randomized studies that were reviewed showed herniated disc surgery to be more effective than chemonucleolysis (A), which, in turn, was shown to be more effective than placebo (A). Chemonucleolysis is an alternative to surgery and involves using the chymopapain enzyme to chemically dissolve the soft nucleus of the disc. The results of surgery are inferior when following failed chemonucleolysis.

Several surgical fusion methods are available to treat degenerative disc disorders or spinal stenosis, but there is no consensus on the definition and importance of spinal “instability”. No randomized controlled trials compare the effects of fusion with conventional treatment, placebo, or with the natural course of degenerative disc disease.

Neck Pain

The studies reviewed address the surgical treatment of chronic pain resulting from whiplash injuries, herniated discs, or spondylosis. Only one randomized controlled trial was found on surgery for spondylosis, with or without herniated disc involvement. This study reported no advantages from surgery . Regarding whiplash injuries, there is no evidence that surgery is superior to conservative treatment.

Psychological Treatment Methods

Psychological treatment methods are used to complement other treatment and are often included as part of the increasingly common multidimensional pain treatment programs. Cognitive behavioral therapy focuses on managing the problems, feelings, thoughts, and behaviors that pain and functional disabilities may cause.

Many randomized controlled studies have addressed cognitive behavioral therapy. Although it is difficult to assess the specific impact of cognitive behavioral therapy in multidimensional programs, studies show that programs which include this type of treatment achieve better results than other types of treatment in patients with chronic back problems (A). This particularly applies to treatment effects on anxiety, physical function, and medication use. Influence of Social Factors Social factors which have been reviewed include: the role of culture and family; the influence of unemployment on the consequences of back pain, its intensity, and duration; the role of access to social welfare payments and early pensions; and the importance of relations with work colleagues and the degree of work satisfaction in this context.

Neck and back pain occur in all societies, but cultural groups differ in how they perceive symptoms and react to them. No scientific evidence shows that genetic factors play a role in the occurrence of back pain, except possibly in disc aging. Many studies show that poor social conditions are closely associated with poor general health status, including back pain. Regarding back problems as a risk factor for unemployment and early retirement, several studies clearly show conflicting results without a clear cause-and-effect relationship. Rather, it appears that age, psychological factors, and access to insurance are important explanatory variables in this context.

Several studies show that neck and back pain are not always isolated clinical problems, but are often associated with other pain, other diseases, stress-related symptoms, and work-related or other social problems. Scientific evidence shows, eg, that negative psychosocial aspects in working life, such as poor work satisfaction and poor relationships with others are associated with higher reporting of neck and back problems. There are no confirmed biological mechanisms that can explain how psychosocial factors would cause back pain, nor any evidence of a direct causal relationship.

Role of Primary Care

Many earlier reviews from different countries have led to evidence based guidelines for care of patients with back pain. These have focused on primary care.

The scientific studies currently available show that the interventions provided within primary care are the only ones needed by most patients with back problems. These studies also show that a primary care physician’s most important task is not to intervene unnecessarily. Subjecting a patient to ineffective examinations and treatments carries the risk, eg, that the patient’s back problem can develop into a chronic, life-long disorder.

Conclusions

While reviewing these conclusions it is important to keep in mind the limited nature of the science behind the conclusions. A Level A Strong evidence rating means that the findings concur in several, randomized
controlled trials of high quality.

The other confidence levels are much less indicative of clearly actionable findings.

Level B Moderate evidence – findings concur in one randomized controlled trial of high quality or one or more randomized controlled trials of low quality, or findings concur in several studies of low quality.
One study regardless of quality in the study of a multivariate, objectively indeterminate condition compounded by psycho-sociological influences is inadequate to draw significant conclusions from other than viable avenues for additional study.

Level C Limited evidence – based on one randomized controlled
trial (of high quality or low quality) or contradictory findings in
several studies. This level is a clear indication of a need for further high quality studies.

Level D No evidence – no randomized controlled trials or other
types of studies of satisfactory scientific quality.

In primary care, the consultation itself offers a major opportunity to influence both the acute and the more long-term course of back problems. An essential aspect of the consultation is the involvement of the caregiver and the ability to work with and listen to the patient’s perceptions on back pain, mainly how it impacts on daily life. The opportunity for the physician and the patient to arrive at a common understanding about the nature and course of back pain is of major importance for the prognosis and is highly dependent on a good patient-doctor relationship.

Pain in the low back and neck is common. Low back pain affects up to 80% of all people at some time during life, and neck pain affects up to 50% of the population. In the overwhelming majority of people, back pain does not signal a serious disease or suggest that one should avoid normal daily activities. On the contrary, scientific studies show that healing is promoted by staying active, returning to work, and exercising at an appropriate and increasing intensity.

A thorough anamnesis and physical examination is important for relieving anxiety about the consequences of pain and sufficient for identifying the patients who should be referred to another specialist for examination and treatment (eg, due to severe infection, specific rheumatic disease, suspected cancer, or other serious conditions).
For most people with back pain, the interventions which can be offered in primary care are the only ones needed. The physician’s attitude and ability to listen to and express empathy with the patient is important for achieving a common understanding with the patient concerning which treatment strategies would be effective. This also has importance for the future course of back pain and compliance with treatment advice.
Back pain and its consequences are not isolated physical problems but are associated with other conditions such as social, psychological, and workplace-related factors. These factors, eg, stress, worry, and anxiety – along with the patient’s own perceptions of and ability to manage the problem – can have a decisive impact on the transition from acute to more chronic pain. The obvious role of psychosocial factors in this respect suggests that such factors should be considered an integral part of back pain in relation to conclusions preventive efforts, in the initial phase of treatment, and later during rehabilitation.
Knowledge on how to prevent back pain is not directly deficient, but has been applied and assessed to a surprisingly small degree. The knowledge currently available should be applied and thoroughly assessed.
The relatively large resources that have been invested locally, regionally, and nationally to prevent and rehabilitate back problems, including interventions to improve the work environment, should be subject to systematic assessment based on current knowledge about the effects of various interventions. The sporadic research on prevention and rehabilitation of back problems should also be assessed in terms of its relevance and scientific quality

.Many treatment methods are currently used, but there is little scientific evidence on their benefits. Some treatment methods are used despite scientific evidence showing that they do not benefit the patient. The appropriateness of subsidizing ineffective treatments with public funds should be investigated.
The primary focus concerning back pain should be on the pain itself and on the human suffering it involves. Furthermore, back pain has an extensive economic impact on the individual and society. The direct healthcare costs and the costs resulting from sick leave and early retirement due to back pain reach an annual sum that is over three times higher than the corresponding costs for all cancer diseases. Against this background, it is remarkable that research on back pain, particularly research related to prevention, pain relief, and rehabilitation is relatively limited in scope. Agencies which have responsibility for and interest in effectively managing back problems should take initiatives to stimulate and focus research in this field, and disseminate information that is currently available, eg, in this report.

Conservative Treatment Methods for Low Back Pain

Medication

Strong scientific evidence shows that muscle relaxants, (eg, benzodiazepines) and anti-inflammatory drugs (NSAIDs) relieve pain in patients with acute and subacute low back problems, ie, problems which have existed up to 3 weeks or up to 12 weeks (A). However, anti-inflammatory drugs can have serious side effects, particularly in elderly people, and muscle relaxants can cause tiredness and dependency, even after short-term use. Furthermore, there is moderate scientific evidence that paracetamol is effective in relieving acute low back pain (B).

Limited scientific evidence suggests that these drugs are effective in treating chronic low back pain (C). For example, only one study was found that compared the effects of muscle relaxants with the effects of placebo (ie, no active treatment), but no such studies address analgesics and NSAIDs in people with chronic low back problems.

There are no studies on the effects of anti-depressants in treating acute low back problems (D). However, moderate evidence suggests that these drugs do not have any effect on pain and mobility in patients with chronic low back disorders (B).

Studies show that only limited evidence supports the treatment effects of colchicine (medication for gout) and cortisone in tablet form (system steroids) on acute low back pain (C).

Serious side effects have been reported for colchicine, but for system steroids such side effects accompany only long-term use.

Injections

Several different types of injections are used at times to treat both acute and chronic back problems. The injections reviewed were: epidural steroid injections, ie, injections in the spinal cord canal, injections in trigger points and ligaments, and injections in facet joints (small joints in the vertebral column).

Limited evidence suggests that epidural steroid injections are more effective than placebo for acute and chronic low back problems involving nerve root pain (C). There are no studies addressing the effects of these injections on acute low back problems without nerve root pain (D). However, moderate evidence suggests that these injections do not have any effects on chronic low back pain without root symptoms (B).

There is no evidence on the effects of injections in trigger points, ligaments, or facet joints (D).

Back School

There is limited evidence on the effects of back school on chronic and acute low back problems (C).

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