We are the generation that worries about climate change. We are the generation making a difference in the world by buying goods whose labels are causing sensory overload with brightly printed, bold-type words such as "organic" and "green" prominently displayed.
And yet this generation might go down in history as the one that, quite literally, internalized an anti-Nature philosophy. We are the Pill Takers. The Age of Aquarius has been co-opted by the CVS ExtraCare Program.
We live in a world where there is a pill to take when we feel a little anxious, a pill to take when we feel a little impotent, a pill to take when we feel a little bald. And no matter how hard they might try, no Madison Avenue type can ever convince me there is anything green or organic about taking several tablets of Dilaudid, OxyContin, or Viagra every day.
Nevertheless, we think we are different, maybe even better than the generation before us.
It becomes an issue for those suffering from chronic pain, who risk, or who now deal with, addiction, kidney failure, or liver failure due to the medications they are prescribed. Perhaps this is why so many primary care providers have recommended nonpharmacologic therapies for the treatment of chronic low back pain, including massage therapy, therapeutic ultrasonography, spinal manipulation, psychological therapies, back school (read my recent blog on the Alexander Technique), yoga, etc.. Of course, to what extent are these various therapies successful?
A consideration of this by the American Pain Society and the American College of Physicians was published in "Annals of Internal Medicine".
The authors found solid evidence that psychological therapies (including cognitive-behavioral and progressive relaxation), exercise, physical therapy, functional restoration, and spinal manipulation are effective for chronic low back pain. When compared to placebo or sham treatments, these therapies generally offered modest benefit, although the effect of exercise was a little less beneficial. There was not much of a difference in efficacy between the various treatment modalities, with a couple of exceptions: Interdisciplinary rehabilitation was moderately more effective than non-interdisciplinary rehabilitation; and Viniyoga was slightly superior to traditional exercises in terms of pain improvement and functionality.
Spinal manipulation was found to be moderately superior to sham manipulation, but there were no differences between manipulation and general practitioner care or pain medications, physical therapy or exercises, and back school. Likewise, there were no differences between massage and manipulation at the end of a course of treatment. Superficial massage was inferior to transcutaneous electrical nerve stimulation (TENS) for pain relief. Studies have found massage similar in effectiveness to corsets and exercise, and moderately better than relaxation therapy, acupuncture, sham laser, and education.
Different modalities of physical therapy were also examined:
• Laser therapy was superior to sham for pain or functional status in one study, but not in another where patients were also receiving exercise.
• Lumbar supports had no more efficacy than spinal manipulation or TENS.
• No differences were found between shortwave diathermy versus sham diathermy or spinal manipulation or shortwave diathermy versus sham diathermy, extension exercises, or traction.
• Traction itself was found to be no more effective than placebo, sham, or no treatment.
• Data on TENS are conflicting, with one study showing TENS superior to placebo, but another trial concluding there was no difference between TENS and sham TENS.
• Conclusions regarding ultrasonography are at best inconclusive.
There have been quite a few studies of psychological therapies for chronic low back pain. Cognitive-behavioral therapy is moderately superior when it comes to short-term pain relief; however, functional status was not improved. No differences were seen between the various psychological therapies and other activities such as exercise or standard low back pain care. The bottom line is that psychological therapies appear to not improve outcomes when added to other noninvasive therapies; but it must be remembered that the diversity of psychological and nonpsychological treatment modalities severely limits interpretability.
Overall, there are several nonpharmacologic options available to patients, demonstrating a similar effectiveness for the treatment of chronic low back pain. Which treatment is "best" for any one patient will depend on the patient's preferences, insurance coverage, convenience, and the availability of skillful practitioners of the given therapy. While these therapies may not replace the pain pill, there is evidence of at least a moderately beneficial role in the treatment of chronic pain.
