Evidence-informed management of chronic low back pain

[Guest guest]

One of our collegaues on Somasimple recently submitted the below post. Members

may find it to be of some interest:

The Spine Journal has just published an enormous, free access, special issue of

reviews of the current evidence for CLBP treatments.

http://www.sciencedirect.com/science/journal/15299430

The Spine Journal

Volume 8, Issue 1, Pages 1-278 (January-February 2008)

Intro (extract):

Patients with chronic low back pain (CLBP) are finding it

increasingly difficult to make sense of the growing list of treatment

approaches promoted as solutions to this widespread problem. Their

confusion is compounded by the financial and emotional cost of

previous failed attempts. This frustration is felt not only by

patients, but by all interested stakeholders, including clinicians

trying to offer accurate advice and provide the most effective

treatment to their patients, and third-party payers responsible for

providing access to reasonable and necessary care. All share a common

goal and wish to use limited healthcare resources to support those

interventions most likely to result in clinically meaningful

improvements in symptoms and functional capacity. The current

approach to the management of CLBP makes this goal virtually

unobtainable.

When a new treatment approach is being considered in fields as

cardiology, infectious diseases, acute trauma, or neurology, there is

a general expectation that adequate research will support its

effectiveness, safety, and cost effectiveness before it is endorsed

as a viable treatment option. With CLBP, however, treatment options

appear virtually endless and increasing every year, have strong and

vocal advocates, and often limited scientific evidence. Treatments

that have never been subjected to methodologically sound randomized

controlled trials are routinely promoted as cures to unsuspecting

patients. Conversely, approaches that have demonstrated only minimal

benefit in clinical trials continue to be recommended by proponents

who allege that such studies were flawed and do not accurately

represent current clinical practice....

Here is a small excerpt from the concluding summary-

Quote:

This special focus issue contains review articles written by

clinicians and researchers who summarized the evidence on 25 classes

of commonly used interventions for CLBP. The wealth of information

provided by these articles cannot be understated and every article

must be read in its entirety to appreciate the particular strengths

and weaknesses of the arguments used by the authors for each

treatment approach. It is also necessary for the reader to look at

the entire special focus issue to obtain an overview of the different

treatment options and place them in perspective. Although it was

initially hoped that global recommendations regarding the use of

specific interventions for CLBP could be made based on the

information presented in each article, this goal has proven to

elusive at this moment. When viewed as a whole, the articles in this

special focus issue pose more questions than they answer. Taken

together, these reviews demonstrate the serious deficiencies in the

available research for many of the treatment approaches that are

commonly used for CLBP because of either unavailable, insufficient,

or conflicting research results. These articles do not present

convincing evidence that it is currently possible to select one

treatment approach over another for patients with CLBP and give very

little guidance on when any specific treatment approach is indicated.

When viewed optimistically, the articles in this special focus issue

do suggest that a reasonable approach to CLBP would include education

strategies, exercise, simple analgesics, a brief course of manual

therapy in the form of spinal manipulation, mobilization, or massage,

and possibly acupuncture. In patients with longstanding or severe

symptoms and psychological comorbidities, there is some evidence that

a comprehensive multidisciplinary approach with cognitive behavioral

treatment, fear-avoidance training, or functional restoration is at

least as beneficial as surgery. This interpretation of the best

available evidence is not materially different than the

recommendations from the Practice Guidelines on Acute Low Back Pain

in Adults that were published by the Agency for Health Care Policy

and Research in 1994 [2]. Although potentially heartening to the many

clinicians who have adopted aspects of this approach, it is somewhat

disappointing to note that 14 years after dozens of highly promoted

new interventions, thousand of studies, millions of lost work days,

and billions of dollars spent on its care, so little has changed in

the evidence available to guide stakeholders and support treatments

for CLBP.

As noted in the review of the economic burden of LBP in this special

focus issue, the magnitude of this problem is likely increasing in

the United States and the question that needs to be answered is

whether any treatment should be offered and widely used before there

being sufficient research evidence to establish its efficacy, safety,

and cost effectiveness. It is a generally accepted principle in most

fields of health care that a treatment should not be offered to the

public until there is sufficient evidence supporting its safety and

effectiveness and a consensus by clinicians of different backgrounds

as to its most appropriate indications and contraindications. It

should be evident to most readers that this is not the norm when

dealing with CLBP and additional research is required to achieve this

long-term goal. In the interim, patients, clinicians, third-party

payers, and policy makers have a responsibility to become thoroughly

familiar with, critically appraise, compare, and openly discuss the

best available evidence presented in this special focus issue. In

this supermarket of over 200 available treatment options for CLBP, we

are still in the era of caveat emptor (buyer beware)....

=================

Carruthers

Wakefield, UK