Did you see what happened this week? There was a new set of Clinical Practice Guidlines published in the Annals of Internal Medicine. The American College of Physicians did a systematic review of the available literature and made some new determinations. For years Primary Care Physicians first line treatment for lower back pain has been prescribing either Non-Steroidal Anti-Inflammatory medications or muscle relaxants (and/or recommending and the over the counter version of an NSAID), however these guidelines suggest that they should now consider non-pharmacological options first. This recommendation applies to both acute onset lower back pain and also for the more chronic version of lower back pain.
The CPG recommended two treatments that we use at FC&R with all of our patients! They recommended using manipulation and exercise both before any medication! In an effort to be completely transparent, they did state that the support for those interventions was of a lower quality, but still higher quality than using medication, which they have been doing for years. However, I have two issues with the idea of the lower quality distinction. First, they did not evaluate when manipulation and exercise are performed together. Secondly, and probably more importantly, they made no mention of what type of exercise programs were provided. Often when these studies are performed, the subjects are simply provided with a uniform series of exercises, without paying any attention to what causes their pain. Is the exercise 30 minutes walking on a treadmill or is it learning how to bend safely? This is the stuff that matters. Another thing that surprised me was the fact that there seems to be moderate quality evidence supporting the idea that moist heat is beneficial in treating both acute and sub-acute lower back pain. For the last several years, I have repeatedly heard that there is little quality evidence that either heat or cold is better for the lower back patient. So I, too, have learned from this CPG! I need to change my recommendations as we move forward. THAT is why these guidelines (and keeping up with the updates) are so important!
So while I am thrilled that the medical community seems to have come to their senses about their recommendations, I do wish that the research could be a little more specific. For now, I guess that we need to be happy that this CPG tells us that what we are doing what is best for our patients. BUT we can never rest on our laurels!
Movement is my Medicine,