Chronic back pain is one of the most common and debilitating medical issues and study that was published in JAMA showed that it is increasing. In 1996 the rate was about 4% and by 2006 it was up to 10% of people over the age of 21. This likely has many factors contributing including the increasing rates of obesity, more sedentary life styles and overall poor health and diet. And despite how common and debilitating this problem is the treatments have changed very little over the last couple decades. Still to this day we treat with physical therapy and pain medications and if that doesn’t work the next option is surgery. And the number of patients for whom all three of these fail is immense. Daily in my practice I encounter at least one patient with chronic intractable back pain that is still intolerable despite all the efforts by the medical community. So have we tried everything?
Of course eating a healthier diet, getting more exercise and losing weight are all proven ways to prevent and/or treat back pain. But these are of course much bigger issues that we all are struggling with. And of course exercising when you have crippling back pain can be near impossible for even the most motivated individual. This leads to a vicious cycle of less activity, more pain, which means even less activity, causing more weight gain and more pain. So if one does not want to resort to surgery (which a study in 2009 Spine showed little benefit at 1 to 2 years followup) then they are left with physical therapy and nonsteroidal anti-inflammatory medications such as ibuprofen and opiate pain medications. Physical therapy likely does have benefit and has almost no harmful side effects so should be tried by everyone with back pain. However, ibuprofen and other nonsteroidal anti-inflammatory medications are well-known to cause kidney problems and stomach and intestinal ulcers. I have had many patients with life threatening stomach bleeds and some who even had to have part of their stomach removed due to long-term use of ibuprofen for back pain. And as for opiate pain medications, they are sedating, decrease mental clarity, can be addictive and due to tolerance often lose their effect over time. They are a blessing to those who need them, but everyone in medicine is agreed that we would gladly get rid of opiate pain medications if we had an alternative. Some resort to spinal injections of steroids or pain medications. These often have short effect with little long-term benefit and can be very expensive.
So have any safer treatment modalities been tested? Well indeed they have. Multiple articles have looked at Vitamin D for people with back pain. A 2009 article in the Journal of the American Board of Family Medicine showed a clear improvement in back pain in those given vitamin D. Again in 2003 Spine showed 95% of back pain patients reported improvement when given vitamin D. The Scandinavian Journal of Primary Care in 2011 also showed this benefit along with many others. Yet have any large randomized trials of vitamin D for back pain been done? Not that I know of. And despite all the evidence above it is still not standard practice (in fact it is hardly ever done) to check vitamin D levels in back pain patients.
And that’s not all. There was a randomized trial in the journal European Review Medical Pharmacology 2000 that showed a statistically significant improvement as compared to placebo with Vitamin B12. But of course the sample was small, only 60, which only makes it that much more impressive that they reached statistical significance. But a larger trial needs to be done.
Then there is omega 3 fish oils, well-known to have an anti-inflammatory effect. In 2006 in the journal Surgical Neurology a controlled trial showed a 59% reduction in nonsteroidal anti-inflammatory medication (such as ibuprofen) use and a 60% reported improvement in pain with omega 3s.
And then there are the copious herbal supplements used for inflammation and joint pain. I already reviewed the literature for turmeric in a previous post and it is still growing daily. There is also an herbal supplement called Boswellia. In a 2003 article in Phytomedicine in a controlled study it was found to have a statistically significant and impressive improvement in arthritis related knee pain. It has not been studied in back pain specifically that I know of but the causes of joint pain and back pain are very closely linked.
Then there there are the more hands on approaches to back pain such as accupuncture, massage and chiropractic work such as manipulation. Each of these actually has a surprising amount of research on each, however these studies are fraught with one main problem, a lack of a good placebo. There really is no control group in these studies as there is no good placebo for massage, or manipulation. There is a sham procedure used to be a placebo for accupuncture that is pretty good as a placebo but still likely not completely inert. However, of the three, accupuncture definitely has the strongest evidence supporting it. A review of studies in 2008 by Cochran and another great review of 11 randomized controlled trials in 2013 in the Clinical Journal of Pain showed a clearly statistically significant benefit of accupuncture. As for physical therapy, massage and chiropractic manipulation the data is not as impressive but mostly because it is of much worse quality. The initial study in 1996 of chiropractic care by Assendelft showed no significant benefit. A 1998 article in New England Journal of Medicine showed little benefit for physical therapy or chiropractic care. However, mostly the lack of benefit seen was in large part due to poor quality studies. Personally I don’t think it has been proven one way or the other and I feel likely both have some benefit but not significantly so. Likely we will never know as studying these is extremely difficult given the lack of a good control group and reliance on patient follow up and cooperation which will be highly reliant on the severity of the patient’s pain. However, I would highly support massage either way as it seems to fix everything and anyone who suffers wtih chronic back pain deserves a good massage.
Chronic back pain has been plaguing our lives for as long as we have walked upright. And as we live longer and have less active lives and live those lives with more pounds on board the problem will only get worse. We need new treatments desperately. Vitamins, omega 3 fish oils, accupuncture and herbal supplements offer treatments that are far less toxic than the medications used today and may allow a patient to delay or hopefully avoid surgery. And these supplements are far cheaper than many of the medications and certainly cheaper than spinal injections. These need to be studied immediately to offer doctors other options for their patients. And if even one of these is found to be as effective as nonsteroidal anti-iflammatory medications such as ibuprofen the savings to the medical system could easily be in the billions.