Who Tells Doctors How to Treat Back Lower Pain?

If you suffer from acute or chronic low back pain, do you lie awake and wonder if anyone is updating your doctor on the latest treatment guidelines? You probably don’t. You’ve got enough going on just trying to turn the volume down on discomfort and have a normal life.

The American College of Physicians

The American College of Physicians (ACP) is an international association of over 150,000 internal medicine specialists. According to their website, their mission is “to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine.” As part of that broad mission, the organization issues clinical guidelines based on published research and evidence. Then, they periodically update them as new data comes in.

Because the organization is composed of internal medicine specialists, who deal with the prevention, diagnosis and treatment of a wide range of adult diseases. Thus, ACP guidelines have been issued dealing with treating many bodily conditions and systems, from anemia to urinary incontinence – including low back pain. They also issue guidelines on screening and prevention practices.

Creating the guidelines is a team effort involving their own Clinical Policy staff, a Clinical Guidelines Committee, and the collaboration of scientific and medical experts.

Guideline updates issued for treating low back pain

This year, 2017, the ACP issued guideline updates for “Noninvasive Treatments for Acute, Subacute and Chronic Low Back Pain.” The most recent previous version came out in 2007. Keep in mind that there are other specialties devoted to diagnosis and treatment of back problems, but often people who have an onset of low back pain will first seek help from their internist, who will evaluate the cause of the pain. If the internist can treat it, they will. If not, they will refer the patient to another type of specialist (chiropractor, orthopedic physician, physiatrist, neurologist, etc.).

For internists who are the first point of contact, and often initiate treatment, here is a summary of what the ACP recommends to its members for treating low back pain that is unrelated to the spinal nerve root:

• The first line of treatment should involve non-drug therapy: exercise, multidisciplinary rehabilitation, and lifestyle methods to ease stress and tension such as yoga, tai chi, acupuncture, meditation and stress management.
• Additional noninvasive approaches include motor-control exercises for core strengthening, biofeedback assisted muscle relaxation, progressive muscle relaxation, low-level laser therapy, spinal manipulation, and cognitive- behavioral or operant therapy.

Note that the emphasis in these first-line interventions are aimed at positive patient change, since these practices do not cause further harm. Also, muscle tension and internal stress tend to make any pain feel worse, so helping the whole person to relax can assist in making a more precise, targeted diagnosis. If the pain does not respond to non-drug therapy, the ACP further recommends:

• Non-steroidal anti-inflammatory medications, followed by drugs such as tramadol or duloxetine (a second-line therapy).
• Opioids should be used only as a last-resort therapy, and patients should be warned about the potential risks vs. benefits.

An underlying principle of this year’s guidelines is the avoidance of needless tests and expensive, possibly harmful medications such as opioids.

Patients whose back pain comes on suddenly should be advised that acute lower back pain due to soft tissue injury (sprain, strain) usually resolves over time, regardless of treatment, provided the patient follows the doctor’s protocol.

The ACP deserves a round of applause for combing through published studies, and revising their guidelines for the noninvasive treatment of low back pain. They should also get special recognition for upholding the universal physician guideline, “Above all, do no harm.”

Facet joint pain

Another source of back pain, other than soft tissue damage, is facet joint pain that occurs when the cartilage pads that cushion and lubricate the small spinal facet joints wears away. While this condition is not reversible, if it’s diagnosed early there are many noninvasive management strategies, very similar to those outlined above by the ACP. However, then conservative approaches such as physical therapy, posture improvement, heat/cold applications and non-steroidal anti-inflammatories are no longer effect, and the resulting nerve pain is interfering with quality of life, there is another noninvasive approach to manage pain by deadening the nerve.

It is called MRI-guided Focused Ultrasound (MRgFUS). It is an outpatient treatment done inside the MRI machine, using beams of ultrasound to stop the pain at its source. For more information, contact the Sperling Medical Group.