Yoga, acupuncture and heat wraps are a few low-tech ways to effectively address low back pain — a major cause of workplace absenteeism — doctors said Monday as they released new treatment guidelines.
The American College of Physicians, a national organization of specialists in internal medicine, published the new recommendations — the first in a decade — in the Annals of Internal Medicine.
Drugless remedies should be first-line therapy, a panel of the organization’s doctors wrote in the journal. They also cautioned against the use of acetaminophen, such as Tylenol, because research since 2007 has found the once widely recommended analgesic is ineffective against back pain.
“Physicians and patients should really seek the treatment that causes the least harm, the least costly,” said Dr. Nitin S. Damle, president of the American College of Physicians.
He said back pain can be acute, lasting fewer than four weeks; subacute, lasting four to 12 weeks; or chronic, lasting more than 12 weeks.
The new guidelines emphasize that opioid painkillers, such as OxyContin and similar drugs, should be considered only as a last resort.
In addition to yoga and acupuncture, the panel of physicians stressed the importance of massage, stress reduction, tai chi, biofeedback, cognitive behavioral therapy, and spinal manipulation, a technique of chiropractors.
“I am a minimalist when it comes to medication so I am in 100 percent agreement with this report,” said Dr. Shaheda Quraishi, a pain management specialist at Northwell Health’s Pain Center in Great Neck.
She and other doctors Monday said most people with short-term back pain invariably improve through low-tech methods, such as exercise and the application of heat.
Quraishi said back pain caused by a herniated disc or pinched nerve can be more complex, especially for patients who complain of sciatica — pain radiating from the back and down the leg. But even for complex pain, physical therapy can help, she said.
When all else fails, the guidelines suggest such medications as duloxetine, sold under the brand name Cymbalta; or tramadol, which Quraishi described as a weak opioid.
Neither drug is ideal, Quraishi said, noting that Cymbalta, a medication prescribed for nerve pain and depression, carries a “black box warning” from the U.S. Food and Drug Administration. That caution means the medication can produce serious side effects in some patients. In Cymbalta’s case, the worrisome side effect is suicide ideation, Quraishi said.
The American Chronic Pain Association estimates that low back pain is the fifth most common reason for doctor visits in the U.S. and one of the most expensive medical complaints, costing the health care system nearly $30 billion annually. About one-quarter of the U.S. workforce misses at least one day within any three-month period. The five percent of U.S. patients treated for severe back pain have even greater absenteeism, according to the association’s data.
Dr. Kiran Patel, director of neurosurgical pain at Lenox Hill Hospital in Manhattan, is Harvard-trained in acupuncture, a procedure she said that works well against low back pain for many patients.
“The pain can come from irritation of the lumbar nerve roots; it can be caused by a bulging or herniated disc or even arthritis in the spine,” she said.
Many patients improve with acupuncture therapy, but not all insurers cover it, said Patel, who is also an assistant clinical professor of anesthesiology and pain medicine at the Hofstra Northwell School of Medicine.