Science of Confusion

This is going to be my more or less critical page, where I cite articles and research as to why there is an answer regarding how to treat spine pain, backed by considerable science, and yet almost nobody, including scientists have heard of it. So my plan on this page is to cite influential journal articles and research, what they concluded, what I think is wrong about it,  as well as what and perhaps why they missed it.

I’ll start off with what I think is the worst offender because it’s so new, so influential, and misses the biggest point in general without being absolutely wrong about anything in particular.

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Ann Intern Med. 2017 Apr 4;166(7):514-530. 

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatmentwith exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

My comments: 

My problem with this paper is its recency. It has prolonged and protracted discussion about the treatment effects of all sorts of therapies from drugs, manipulation, massage, acupuncture, yoga, exercise, etc., with zero appreciation with regards to what brought on the back pain in the first place. Which is perhaps what you should expect when you read the authors other papers and see that none of them are back pain specialists but rather specialists in writing “clinical guidelines.”

Throughout the text you read that low or moderate quality evidence finds at best small to moderate effects sizes (meaning never more than a 2 point drop in pain on a 10 point scale) for short term pain and generally no, or if lucky a 1/10, effect on long term pain. The overall conclusion that they don’t state explicitly, is that you might as well try a number of placebo based treatments because they work as well as medicinal treatments, because whether the medicine is real or not does not affect true cause of pain anyway.  And at least the placebo treatments have less side effects.

Also I don’t like how they promote the cheery picture with acute pain that things should just get better regardless…

“Clinicians should inform all patients of the generally favorable prognosis of acute low back pain with or without sciatica, including the likelihood of substantial improvement in the first month. Clinicians should also provide evidence-based information with regards to their expected course, advise them to remain active as tolerated, and provide information about effective self-care options.

…because if you don’t address the causes of spine degeneration and pain, you are screwed in the long run. Which explains why relatively simple overuse disorders like neck and back pain have become the number 4 and 1 sources of disability worldwide. Just “hey, it usually gets better,” “put a hot pack on it” and “stay active” isn’t the best advice out there.

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