What does 'the science' say for Lower Back Pain treatment?

I have analysed 3 systematic reviews concentrating on treatment for lower back pain (LBP) covering 3 areas: acupuncture, spinal adjustments and exercise therapy. Systematic reviews are a round up of a topic within academic literature where many studies within the same topic are bulked together and analysed.

Read on for a summary of the evidence provided for each of these 3 areas.

Summary of Systematic reviews for lower back pain and acupuncture treatment:

Number of studies and participants: 16 systematic reviews covered within this summary and this totals 5931 individuals studied. The method used was acupuncture, sham (sham seeks to deliberately fool the individual being treated into thinking acupuncture is occurring when it is not) acupuncture, no treatment and placebo.

Key findings presented: For acute LBP there was little to no improvement but with chronic (typically defined as LBP lasting longer than 12 weeks) there was short term pain relief.

Quality of evidence: Rated as Low overall.

My interpretation: There are 2 areas that surprised me from these results and 1 that does not.

I am surprised that the quality of evidence was rated so low by this review, particularly as acupuncture points are always the same. Within LBP this is the 'Bladder meridian'. I would have thought that the consistency of using the same points would improve the quality of the study.

I am also surprised that there was not more improvement for acute LBP with acupuncture. Acute LBP typically has an inflammatory mechanism that is causing at least part of the pain. Acupuncture reduces inflammatory markers in the body by:

• Activating the vagus nerve which has an anti inflammatory response

• The needles stimulate endorphin release from the brain, which also reduces inflammation

• Acupuncture leads to the production of cortisol which stimulates the release of anti-inflammatory cytokines

I am, however, not surprised that chronic LBP benefits were only short lived. Acupuncture tends to offer a 2 days rest bite from chronic LBP. Where I have had a lot of success with acupuncture is by viewing this 2 day rest bite as an opportunity. This is a window within which you can strengthen your lower back. I have my patients do 5 mins a day of holding - isometric - strength exercises. Over the course of 4-6 weeks I have witnessed elderly people going from being unable to walk more than 5m to walking for 40 minutes, pain free. Stronger muscles means your joints in your lower back do less work.

Summary of systematic reviews on spinal adjustments (manipulations) for lower back pain

Number of studies and participants: This review studied 47 randomly controlled trials with 9211 participants. Individuals were attributed to exercise, no treatment, sham treatment and spinal adjustments within the studies.

Key findings presented: Spinal adjustments produced similar results to other treatments in cases of chronic lower back pain, but produced better results for improvements in function for people in the short term.

Quality of evidence:  Graded as moderate to high. Most likely due to the fact that this was a systematic review of randomly controlled trials (RCT) as RCT hold a higher level of evidence due to their design and methodology.

My interpretation:  Spinal adjustments can be an excellent treatment for easing LBP. I have found that when the pain is caused by tightness, or restrictions, this to be particularly true. I have, personally, had less success with chronic LBP and spinal manipulations.

In a practical treatment setting I would use spinal adjustments alongside many other treatment modalities. I am not in favour of simply adjusting someone's lower back and showing them the door. For example, spinal adjustment can cause local inflammation and patients often respond well to dry needling immediately after the adjustment has occurred. This has the added benefit that as the needles work away I can then treat another area, be it the glutes or mid back.

Lastly, spinal adjustments do have a risk factor to bones and blood vessels due to the high velocity nature of them. As such, many of my patients are not able to receive this form of treatment. I personally work in an area where there is a high demographic of elderly people and so I have developed other skills to treat patients without using spinal adjustments.

Summary of systematic reviews on exercise therapy and lower back pain

Number of studies and participants:  249 randomly controlled trails with 24,284 participants. Participants were spread across exercise, no treatment, placebo or other treatments. 'Other treatments' covered spinal manipulations, massage, ultrasound and back care education.

Key findings presented: Improvements when compared to no treatments and placebo and small improvement compared to other treatments.

Quality of evidence: Overall rated as having a low level of evidence.

My interpretation: Within this study the exercises included for exercise therapy was Tai Chi, Yoga, sling exercises, core strengthening, motor control exercises and aquatic exercises.

This presents a wide ranging number of exercises which you would expect with the numbers involved. This lead to a small improvements of LBP with exercise therapy. I would have liked to have seen a more holistic approach to LBP and exercises. So rather than spreading people across different areas I would like to have seen a number of exercises combined to make a holistic impact on the lower back. For example, core strengthening with lower back muscle strengthening and tai chi.

I feel that the complexities of our bodies necessitates a more holistic approach to treatment than single exercises.