How effective are common treatments for chronic back pain?

Chronic low back pain affects about 10% of the population.1 Healthcare providers consider back pain as chronic when it lasts longer than six months and when they believe it will last indefinitely.

Most people with chronic back pain do not seek healthcare for it on a regular basis.2 Presumably, they are neither distressed nor impaired enough to seek care. However, some people do suffer from chronic back pain and consequently seek the advice of healthcare providers.

There are many common treatments for chronic back pain:

  • Anti-inflammatory medications & acetaminophen
  • Muscle relaxant medications
  • Antidepressant medications (used for pain)
  • Anticonvulsant medications (used for pain)
  • Opioid, or narcotic, medications
  • Chiropractic care
  • Physical therapy
  • Cognitive behavioral therapy
  • Epidural steroid injections
  • Rhizotomy
  • Back surgeries – laminectomies, disctectomies, and fusions
  • Implantable pain control devices – spinal cord stimulators and intrathecal drug delivery systems (aka “pain pumps”)
  • Chronic pain rehabilitation programs

Many of these therapies and procedures have been shown in research to be effective in reducing pain and reducing disability. However, effective, in this regard, does not mean curative, as none of them cure chronic back pain. As such, it is important to know something about how effective they are. The following information is a review of the research literature on their relative effectiveness.

Anti-inflammatory medications & acetaminophen

Anti-inflammatory medications and acetaminophen are commonly used for back pain. On average, these medications have been shown to be mildly to moderately effective in reducing chronic pain.3 The quality of this research is good.4 

Muscle relaxant medications

In their review of the research, Chou and Huffman4 found that muscle relaxants, on average, were moderately helpful in reducing acute back pain. Studies testing the effectiveness of muscle relaxants for chronic back pain are lacking.

Antidepressant medications

In meta-analyses, anti-depressant medications are moderately helpful in reducing chronic back pain, but do not tend to improve daily functioning.5, 6 Tricyclic antidepressants, in particular, have the best quality of research evidence supporting their effectiveness.

Anticonvulsant medications

While noting the effectiveness of anticonvulsant medications for neuropathic pain, Chou and Huffman4 report that they found only one study of the effectiveness of anticonvulsant medications for chronic back pain. The study showed that topiramate is modestly better than placebo.

Opioid, or narcotic, medications

Opioid, or narcotic, pain medications are commonly used for chronic back pain. Despite their common use, there is little research on the long-term effectiveness of opioids for chronic back pain.In their review of this research, Kroenke, Krebs, and Bair8 found that the use of opioid medications on a short-term basis is modestly better at reducing pain than placebo. However, they also found that opioids were no better than non-narcotic pain medications in reducing pain. Moreover, they found that opioid medications were slightly less effective than non-narcotic pain medications on functional outcomes (i.e., helping patients to do more things).

In their meta-analysis of the research, Martell, et al.,9 found that opioid medications are no better than placebo when it comes to reducing pain.

Ballantyne and Shin10 reviewed evidence showing that opioids lose their effectiveness over time because of tolerance. In actual practice, what this means is that, over time, patients commonly need periodic increases in their dose of opioids in order to get the same level of pain relief. Tolerance is a significant problem. Assuming they have a normal lifespan, most patients eventually get so tolerant to opioids that the medications become ineffective.

Addiction, of course, is also a significant problem. In the pain management field, addiction is defined as a loss of control over the use of opioid medications or continued use of the medications despite harm.11 In their meta-analysis cited above, Martell, et al.,9 found that upwards of 20% of patients on opioid pain medications demonstrate problematic behaviors that are suggestive of addiction.

Chiropractic care

Chou, Atlas, et al.,12 note that spinal manipulation, typically performed by chiropractors, is moderately helpful in reducing chronic back pain. They also note that the quality of research evidence to support its effectiveness is good.

Physical therapy

Hayden, et al.,13 and Chou, Atlas, et al.,12 found good evidence that physical therapy is mildly to moderately helpful in reducing pain.

Cognitive behavioral therapy

Numerous investigations into the effectiveness of cognitive behavioral therapies for back pain have found good evidence for moderate to substantial reductions in pain.12, 13, 14, 15 

Epidural steroid injections

Research on the outcomes of epidural steroid injections consistently shows that they are ineffective on average.16, 17, 18, 19, 20 

Rhizotomy

In a well designed study, Van Wijk, et al.,21 tested rhizotomy, or radiofrequency neuroablation, against a sham procedure. Like a placebo, a sham procedure is a feigned procedure where patients do not know it is not the real thing. They randomized patients into two groups – 40 patients receiving the real rhizotomy and 41 patients receiving the sham rhizotomy. The evaluators and the patients did not know which procedure the patients received. The investigators found no difference between the two groups in pain levels, activity levels, or intake of analgesic medications.

These results echoed a previous, double-blind study of rhizotomy versus sham rhizotomy.22 This earlier study did not find any significant difference at 12 weeks follow-up.

Back surgeries

There are few studies on the effectiveness of back surgeries for chronic back pain. In their attempt to review the research, Mirza and Deyo23 found only five published, randomized clinical trials for fusion surgery. Two had significant methodological problems, which prevented them from drawing any conclusions. One of the remaining three showed that fusion surgery was superior to conservative care. The other two compared fusion surgery to one session of group-based cognitive behavioral therapy. These two studies found no differences between the surgical and psychological interventions at one and two year follow-up periods.

In their review of the literature, Gibson & Waddell24 concluded that there is only minimal evidence that lumbar surgeries are sometimes effective in reducing low back pain.

Implantable pain control devices

Research on spinal cord stimulators suffers from poor quality studies. The majority of all published studies are studies of the effectiveness of spinal cord stimulators for chronic leg pain originating in the low back and not for chronic back pain itself. A number of reviews of these poor quality studies show that there is limited evidence to support the effectiveness of spinal cord stimulator implants.12, 25, 26 

Research on the effectiveness of intrathecal drug delivery systems (aka “pain pumps”) also suffer from poor quality. In their review, Turner, Sears, & Loeser27 found that intrathecal drug delivery systems were modestly helpful in reducing pain. However, because all studies were observational in nature, support for this conclusion is limited.28

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are a traditional, interdisciplinary rehabilitation approach combining multiple healthy lifestyle changes, such as exercise, with cognitive behavioral interventions, and non-narcotic medication management. Such programs focus on reducing pain, returning to work or other life activities, reducing the use of opioid pain medications, and reducing the need for obtaining healthcare services. Multiple reviews of the research highlight that there is high quality evidence demonstrating that these programs are moderately to substantially effective.29, 30 

In his review of the research, Turk31 found that patients in chronic pain rehabilitation programs reduce pain on average by approximately 35%, even after reducing opioid pain medications.

Multiple studies show rates of returning to work from 29-86% for patients completing a chronic pain rehabilitation program.30 These rates of returning to work are higher than any other treatment for chronic back pain.

Additionally, a number of studies report significant reductions in utilizing healthcare services following completion of a chronic pain rehabilitation program. For example, Gatchel & Okifuji30 reviewed multiple studies showing that 60-90% of program completers do not seek additional healthcare services for their chronic pain, even at one year follow-up.

As is evident, there are many common treatments and procedures for chronic back pain and they differ in their degree of effectiveness.

References

1. Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., Castel, L. D., Kalsbeeck, W. D., & Carey, T. S. (2009). The rising prevalence of chronic low back pain. Archives of Internal Medicine, 169, 251-258.

2. Cote, P., Cassidy, J. D., & Carroll, L. (2001). The treatment of neck and low back pain: Who seeks care? Who goes where? Medical Care, 39, 956-967.

3. Koes, B. W., Scholten, R. J., Mens, J. M., & Bouter, L. M. (1997). Efficacy of non-steroidal anti-inflammatory drugs for low back pain: A systematic review of randomized clinical trials. Annals of the Rheumatic Diseases, 56, 214-223

4. Chou, R., & Huffman, L. H. (2007). Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147, 505-514.

5. Onghana, P. & Van Houdenhove, B. (1992). Anti-depressant-induced analgesia in chronic non-malignant pain: A meta-analysis of 39 placebo-controlled studies. Pain, 49, 205-219.

6. Salerno, S. M., Browning R., & Jackson, J. L. (2002). The effect of antidepressant treatment on chronic back pain: A meta-analysis. Archives of Internal Medicine, 162, 19-24.

7. Chou, R., Ballantyne, J. C., Fanciullo, G. J., Fine, P. G., & Miaskowski, C. (2009). Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. Journal of Pain, 10, 147-159.

8. Kroenke, K., Krebs, E. E., & Bair, M. J. (2009). Pharmacotherapy of chronic pain: A synthesis of recommendations from systematic reviews. General Hospital Psychiatry, 31, 206-219.

9. Martell, B. A., O’Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., Fiellin. D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

10. Ballantyne, J. C. & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. Clinical Journal of Pain, 24, 469-478.

11. American Academy of Pain Medicine and the American Pain Society. (1997). The use of opioids for the treatment of chronic pain: A consensus statement. Clinical Journal of Pain, 13, 6-8.

12. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.

13. Hayden, J. A., van Tulder, M. W., Malmivaara, A. V., & Koes, B. W. (2005). Meta-analysis: Exercise therapy for nonspecific low back pain. Annals of Internal Medicine, 142, 765-775.

14. Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26, 1-9.

15. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.

16. van Tulder, M. W., Ostelo, R., Vlaeyen, J W., Linton, S. J., Morley, S., & Assendelft, W. J. (2001). Behavioral treatment for chronic low back pain: A systematic review within the framework of the Cochrane Back Review Group. Spine, 26, 270-281.

17. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406.

18. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862.

19. Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (Updated March 30, 2007). Injection therapy for subacute and chronic low back pain. In Cochrane Database of Systematic Reviews, 2008 (3). Retrieved April 22, 2012.

20. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

21. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

22. Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

23. Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.

24. Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

25. Taylor, R. S., Van Buyten, J., & Buchser, E. (2005). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine, 30, 152-160.

26. Turner, J. A., Loeser, J. D., Deyo, R. A., & Sanders, S. B. (2004). Spinal cord stimulation for patients with failed back syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain, 108, 137-147.

27. Turner, J. A., Sears, J. M., & Loeser, J. D. (2007). Programmable intrathecal opioid delivery systems for chronic noncancer pain: A systematic review of effectiveness and complications. Clinical Journal of Pain, 23, 180-195.

28. Patel, V. B., Manchikanti, L., Singh, V., Schultz, D. M., Hayek, S. M., & Smith, H. S. (2009). Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. Pain Physician, 12, 345-360.

29. Flor, H., Fydrich, T. & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

30. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

31. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain, 18, 355-365.

 

Date of publication: September 13, 2012

Date of last modification: October 23, 2015

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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