Fads in the treatment of low back pain

Article Abstract:

Low back pain is one of the most common complaints expressed by patients in the United States. It is also a major cause of absenteeism. Over the years, fads have come and gone in the treatment of low back pain. In the October 3, 1991 issue of The New England Journal of Medicine, researchers showed that a currently popular treatment, the injection of steroids (methylprednisolone) into the facet joints in the backbone, is yet another procedure that provides no significant benefit. The question must be raised, "Why, if low back pain contributes to so much pain and economic loss, is so little known about it?" There are several factors that render the problem insidiously difficult to study. One is the lack of standardized diagnostic criteria. There is no objective measure for pain, and standard techniques, such as seeing how far the patient can bend over, are crude at best. It is also clear that psychosocial factors play a strong role in back pain. Patients complaining of low back pain are often influenced by depression, job dissatisfaction, drug or alcohol abuse, and the prospect of worker's compensation. Furthermore, the placebo effect seems to be particularly strong for low back pain. In the evaluation reported in the present issue, one-third of the patients reported marked relief of back pain after receiving treatment they did not known to be only saline. A truly effective treatment must be able to ease the pain for a large number of patients simply to exceed this placebo effect. This may prove to be impossible, since there is no reason to assume that all the test patients suffering low back pain are indeed suffering from the same underlying condition. The identification of effective treatments for low back pain will require scrupulous application of the principles of scientific research. Research reports must also identify potential conflicts of interest on the part of the researchers. An indication that some back pain treatment is effective may mean a great deal of profit for some practitioners. While entrepreneurial spirit can produce innovation, it is rarely responsible for scientific objectivity. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Drug therapy, Corticosteroids, Adrenocortical hormones, Fads, editorial

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A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain

Article Abstract:

Chronic low back pain is a common affliction, but therapeutic approaches remain largely unevaluated. One method, transcutaneous electrical nerve stimulation (TENS), uses electrical stimulation. TENS is in widespread use, is approved for payment by most insurers, including Medicare, and cost the Veterans Administration almost $2 million in 1986. Exercise and stretching constitute major aspects of another group of approaches. In spite of their popularity, neither method has been subjected to evaluation in controlled clinical trials. This issue was addressed by assigning patients with chronic low back pain to one of four treatment groups: TENS alone (36 patients), TENS plus exercise (37), sham (simulated) TENS without exercise (36), and sham TENS plus exercise (36). Treatment success was measured in four areas, comprising functional status, pain ratings, physical measures, and the use of medical services. Results after one month demonstrated no differences in outcome between subjects who received TENS (47 percent improvement) and those who received sham TENS (42 percent improvement). However, exercise seemed helpful in several areas, such as increased activity and reduced pain frequency. The exercise groups reported 52 percent improvement, while patients who did not exercise reported 37 percent improvement. Even for patients who exercised, however, overall functioning did not improve. The results, on the whole, indicate that the current widespread use of TENS may be unwarranted, and certainly suggest that further controlled trials should be instituted. They also indicate that active approaches, rather than passive ones, work better in treating back pain. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Exercise therapy, Transcutaneous electrical nerve stimulation

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Low back pain

Article Abstract:

The diagnosis and treatment of low back pain is reviewed. Topics include medical history, physical examination, differential diagnosis, diagnostic imaging, natural history, herniated intervertebral disks, spinal stenosis, and chronic low back pain.

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