Medications might temporarily relieve low back pain (LBP), but non-pharmaceutical remedies carry less risk and can attack the actual causes.
Several workers’ compensation experts say a newly released guidance for treating the condition includes recommendations that can lead to better function and quicker returns-to-work for injured workers.
LBP is one of the most common ailments among injured workers and can be one of the costliest, depending on the treatment. Recommendations from the American College of Physicians suggest payers could significantly reduce expenditures and see the same or better results.
“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment,” said Dr. Nitin S. Damle, president of the ACP. “Physicians should avoid prescribing unnecessary tests and costly and potentially harmful drugs, especially narcotics, for these patients.”
Avoiding medication for effectiveness
Called “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain,” the guidance was published in the Annals of Internal Medicine. It is based on systematic reviews of literature in what the organization says is “a rigorous process based on extensive review of the highest quality evidence available, including randomized control trials and data from observational studies.” It indicates non-pharmaceutical treatments were generally more effective than nearly all medications used to treat patients with acute, subacute and chronic LBP.
“It’s always been our recommendation that the first approach is non-pharmaceutical,” said Dr. Robert Hall, corporate medical director for the workers’ comp and auto no-fault pharmacy benefit management division of health services company Optum. “One of the things I think about when I see these recommendations is: it’s not that non-pharmaceutical treatments are meant to delay medications, but to help be therapeutic. Most pharmaceuticals provide symptom relief, but this may bring about actual recovery.”
For acute and subacute LBP the guidance recommends superficial heat, massage, acupuncture, or spinal manipulation. (Photo: Shutterstock)
The three recommendations in the guidance are based on when the injury occurred. Acute is defined as less than four weeks; subacute is four to 12 weeks; and chronic is classified as pain lasting more than 12 weeks. Experts say the date of injury is important to help determine what actions to take.
“Tissues are in a different state of healing. So having specific recommendations based on date of onset of pain can help clinicians be more specific in terms of the treatment injured workers are receiving,” Hall said. “So, you don’t just pick one [treatment], there’s actually more selectivity based on how long ago the injury occurred. That’s consistent with what we’ve seen.”
“The first thing we do is look at whether it is acute, subacute or chronic,” said Daniel Sanchez, vice president of operations for Onsite-Physio, and a physical therapist. “It will change how you start the treatment.”
For acute and subacute LBP the guidance recommends superficial heat, massage, acupuncture, or spinal manipulation. “If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants…”
In addition to the ACP’s non-pharmaceutical recommendations, Sanchez said gentle range of motion exercises and soft tissue mobilization are also beneficial for injured workers with acute or subacute LBP. “The biggest thing you want to do is maintain that mobility,” he said. “You don’t want them to over-rest; keep them moving.”
For patients who don’t respond well to non-pharmacologic treatments, the guidance suggests using nonsteroidal anti-inflammatory drugs first, then tramadol or duloxetine as second line therapy. (Photo: Shutterstock)
Treatments for chronic conditions
For chronic LBP, the ACP recommends starting treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, Tai Chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy or spinal manipulation.
For patients who don’t respond well to non-pharmacologic treatments, the guidance suggests using nonsteroidal anti-inflammatory drugs first, then tramadol or duloxetine as second line therapy. Opioids should be considered as an option only when other treatments have failed and only if the potential benefits outweigh the risks and the clinician has discussed both with the patient.
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“For the treatment of chronic low back pain, physicians should select therapies that have the fewest harms and costs, since there were no clear comparative advantages for most treatments compared to one another,” Dr. Nitin S. Damle, president of the ACP. “Physicians should remind their patients that any of the recommended physical therapies should be administered by providers with appropriate training.”
In working with injured workers with chronic LBP, Sanchez advocates additional non-pharmaceutical treatments. “You really want to work on core and stability, working on that core strength and making sure the person has the stability to do all the things he needs to do,” he said. “General core strengthening and abdominal strengthening exercises are important.”
In addition to getting injured workers’ buy-in to expedite the healing process, it’s crucial for clinicians to look beyond just the initial injury. (Photo: Shutterstock)
The healing process
Helping injured workers recover quickly from LBP entails getting them the best treatment for them. The ACP guidance said the research did not indicate which patients are likely to benefit from which specific therapy. Working in collaboration with injured workers will help ensure clinicians provide the most appropriate treatment.
“In the old days, doctors told patients to take a pill and stay in bed for a week,” said Dr. Melissa Broadman, senior vice president for pharmacy and utilization review at Sedgwick. “The ACP’s guidance is a positive step in the right direction.”
In addition to getting injured workers’ buy-in to expedite the healing process, it’s crucial for clinicians to look beyond just the initial injury. “One of the things we miss in terms of the medical community that we need to do a better job of is identifying underlying comorbid conditions,” Hall said. “Things that pop out are patients that are obese, have underlying anxiety or depression, and smokers . .. It’s such a huge part of what we have to overcome with these spine conditions — understanding what the effects of comorbid conditions can have.”
Nancy Grover is the founder and president of NMG Consulting, a media/communications entity based in Florida. Grover’s specialties include insurance, workers’ compensation, financial services, substance abuse, healthcare and disability. She can be reached at firstname.lastname@example.org.