Prevention

In view of the enormous personal, societal, and financial burden of back pain, numerous preventive approaches have been investigated. A systematic review of prospective, controlled trials of interventions to prevent back pain in working-age adults identified 20 trials that met inclusion criteria. Only exercise, in seven of eight trials, was found effective in preventing self-reported episodes of back pain. A variety of exercise approaches were used, including stretching; strengthening of abdominal, back, and leg muscles; and general conditioning. Interventions found ineffective in reducing back pain episodes included stress management, shoe inserts, back supports, ergonomic and back education, and reduced lifting programs. Although evidence for efficacy in prevention of back pain is lacking, smoking cessation and reduction to appropriate weight for height should be encouraged because both smoking and obesity have been associated with increased severity of back symptoms.

Exercise and Physical Therapy

For most patients with acute (< 4 weeks) back or neck pain, there is little evidence that formal physical therapy is necessary. The best advice for such patients is probably to continue with their usual activities as tolerated. In fact, early referral to physical therapy prolonged the duration of symptoms compared with patients simply advised to stay active. A self-administered instrument, the Keele STarT Back Screening tool, was developed and validated to stratify the intensity of initial treatment in patients with back pain in the primary care setting. The nine-item tool categorizes patients into three groups based on risk of long-term disability. Low-risk patients may be treated with a single education session. Patients categorized as medium risk require formal physical therapy referral, and high-risk patients are referred for “psychologically informed physical therapy.”

For most patients with persistent chronic neck or back symptoms, exercise therapy is the cornerstone of medical treatment to decrease pain and restore function and mobility. An impairment-based manual physical therapy and exercise program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain compared with a program composed of advice, mobility exercise, and subtherapeutic ultrasonography. Similarly, one meta-analysis found that exercise therapy was effective at decreasing pain and improving function in adults with chronic low back pain and may reduce work absenteeism in patients with subacute symptoms. Unfortunately, studies comparing different exercise approaches, including stabilization, McKenzie, Pilates, and general aerobic conditioning, are insufficient to strongly recommend a single approach in a particular subset of patients. However, studies have suggested that selection of a physical therapy approach based on diagnosis or mechanical assessment is more effective than general nonspecific exercise advice.

General aerobic conditioning is often recommended for patients with chronic neck or back pain. The sense of well-being and accomplishment acquired from a planned aerobic exercise program such as walking, running, cycling, or swimming creates a positive treatment milieu and further establishes the extent of patient motivation and commitment to the overall treatment plan. Patients participating in an aerobic exercise program have been shown to receive fewer prescriptions for pain, were given fewer physical therapy referrals, and had improved mood states and lessened depression.

Evidence suggests the superiority of neck stabilization exercises, with some advantages in pain and disability outcomes, compared with isometric and stretching exercises in combination with physical therapy agents (transcutaneous electrical nerve stimulation, continuous ultrasonography, and infrared irradiation) for the management of neck pain. There is moderate evidence that lumbar stabilization exercises are effective in improving pain and function in a heterogeneous group of patients with chronic low back pain. Unfortunately, available studies are unable to define a specific subgroup of patients with chronic low back pain most suitable for this exercise approach. The current evidence suggests that in the short term, lumbar extensor strengthening exercise administered alone or with co-interventions is more effective than no treatment and most passive modalities in improving pain, disability, and other patient-reported outcomes in chronic low back pain.

Yoga and Pilates exercises have grown in popularity and represent two mind-body exercise interventions that address both the physical and mental aspects of pain with core strengthening, flexibility, and relaxation. There has been a gradual trend toward inclusion of these nontraditional exercise regimens into treatment paradigms for back pain, although few studies critically examining their effects have been published. Two systematic reviews of Pilates for low back pain concluded the evidence was inconclusive that Pilates is effective in reducing pain and disability in patients with low back pain. Evidence that yoga is beneficial for low back pain is more robust. These trials suggest that there is reasonably strong evidence that yoga is superior to usual care in chronic back pain in pain and general health measures, particularly at 6 months.

The McKenzie method is a unique and comprehensive approach to neck or low back pain that includes both assessment and intervention. The assessment is designed to detect a directional preference, which refers to a particular direction of movement or sustained posture that causes symptoms to centralize, decrease, or be abolished. Centralization is defined as the sequential and lasting abolition of all distal referred symptoms and subsequent abolition of any remaining spinal pain in response to a single direction of repeated movements or sustained postures. The finding of centralization has positive prognostic value, provided treatment is guided by assessment findings. Noncentralization is a strong predictor of poor prognosis and correlates well with “nonorganic” signs. In limited clinical trials, McKenzie-based therapy produces results comparable with those of stabilization or strengthening programs.

Aquatic exercise is potentially beneficial to patients suffering from chronic low back pain and pregnancy-related low back pain. Patients with barriers to land-based programs, including lower extremity joint disorders and obesity, are often able to exercise actively in the pool.

Medication

In addition to passage of time, participation in an active exercise program, and use of nonpharmacologic treatments, medicinal treatment is a common component of medical management of neck and back pain. Medications commonly used for low back pain include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, skeletal muscle relaxants (for acute low back pain), and antidepressants (for chronic low back pain).

Acupuncture

Acupuncture is based on Chinese traditions and concepts dating to more than 2000 years ago. Illness in classical Chinese medicine is defined by disharmony or imbalance in yin and yang , with resultant disruption in the flow of qi in the various meridians or channels through which it flows. In this paradigm, treatment requires insertion of needles in specific points to influence movement of qi , tonify deficient yin or yang , or disperse excess yang. As acupuncture has become established in the West, studies investigating its physiologic effects have demonstrated multiple potential explanations for an analgesic effect.

Acupuncture has been increasingly accepted as a useful modality in the treatment of back and neck pain. Approximately two thirds of pain specialists and rheumatologists report referrals to practitioners of acupuncture. A National Institutes of Health consensus conference in 1998 concluded that acupuncture might be useful as an adjunct treatment for low back pain or an acceptable alternative to be included in a comprehensive management program. Ten years later, the American College of Physicians and American Pain Society guideline on the diagnosis and treatment of low back pain recommended that acupuncture be considered as a nonpharmacologic treatment with proved benefits for patients with chronic or subacute, nonspecific low back pain. A systematic review of the effectiveness of acupuncture for back pain found 23 randomized, controlled trials including more than 6000 patients. This analysis concluded that there is moderate evidence that acupuncture is more effective than no treatment and strong evidence of no significant difference between acupuncture and sham acupuncture for short-term pain relief. The authors also concluded that there is strong evidence that acupuncture can be a useful supplement to other forms of conventional treatment for nonspecific low back pain.

A reasonable trial of acupuncture in most patients requires 6 to 10 treatments, perhaps more in older patients. Acupuncture is contraindicated in patients with severe bleeding disorders or systemic infection. Electroacupuncture should be avoided in patients with pacemakers, defibrillators, implanted medication pumps, and implanted neuromodulating devices. In pregnant patients, acupuncture points that may stimulate labor are “forbidden.” Opioid-dependent patients may be less responsive to acupuncture. Serious complications of acupuncture such as organ or vascular puncture are extremely rare.

Manipulation

Spinal manipulation is defined as the application of high-velocity, low-amplitude manual thrusts to the spinal joints with movement beyond the passive range of motion. Chiropractors perform more than 90% of all manipulations in the United States, but other practitioners include osteopathic physicians and physical therapists. Almost 90% of visits to chiropractors are for neck or back pain.

Manipulation techniques vary considerably based on the training of the practitioner. In general, osteopathic manipulation uses a long-lever, lower-velocity technique using a long bone such as the femur to apply force to one or more joints. Short-lever, higher-velocity manipulation of a specific joint represents the more commonly performed chiropractic spinal “adjustment.” More recently, medicine-assisted manipulation has been reintroduced, primarily in the chiropractic community. This technique involves spinal manipulation after local anesthesia (epidural or facet) or with deep conscious sedation. To date, medicine-assisted manipulation has not been evaluated in a controlled trial.

The precise mechanism of action for any effects attributed to manipulation remains unknown. Current hypotheses focus on either direct effects on the facet joints themselves or secondary neurologic effects of facet and myofascial manipulation. Manipulation may release trapped synovial plica, alter orientation of the joint, relax periarticular hypertonic muscles, disrupt adhesions, or unbuckle abnormal motion segments. There is some evidence that manipulation may affect afferent nerves in the paraspinal musculature, inhibiting excessive reflex activity and potentially affecting central pain processing.

For patients with acute or subacute low back pain, manipulation has been shown to be superior to sham manipulation but not statistically or clinically superior to general care, analgesics, physical therapy, exercises, or back schools. In a randomized clinical trial, patients with acute and subacute back pain treated with osteopathic manipulation required significantly less medication than the standard care group, however. In another large, prospective, randomized trial comparing chiropractic manipulation with medical care, including physical therapy, similar outcomes were noted in pain and disability, but patients treated with manipulation had a greater likelihood of perceived improvement. For mechanical neck pain, manipulation in addition to exercise was found superior to waiting list controls for pain reduction in a systematic review of 33 trials.

Mild adverse effects of spinal manipulation occur in 30% to 61% of all patients. Most of these effects occur within 4 hours of treatment and resolve the same day. The most common symptoms reported include local discomfort (53%), headache (12%), tiredness (11%), radiating discomfort (10%), and dizziness (5%). Serious adverse affects of lumbar manipulation such as disc herniation or cauda equina syndrome are rare, estimated at 1 event per 3.72 million manipulations. Risk of serious injury from cervical manipulation, particularly vertebral artery dissection, is well described, but the frequency is unknown. Although likely rare, the consequences of this complication are potentially catastrophic, such that some have suggested avoidance of cervical manipulation in patients with known atherosclerotic cardiovascular disease.

Massage

Massage, defined as manipulation of muscle and fascia using one’s hands or a mechanical device, is a widely used adjunctive treatment in patients with neck and back pain. Common variations of massage include rolfing, Swedish massage, acupuncture massage, myofascial release, and craniosacral therapy. Therapeutic benefits of massage have been attributed to local effects, including increased blood flow and oxygenation of tissues and relaxation of tight muscles. Other proposed mechanisms include stimulation of serotonin or endorphin release, as well as effects on pain transmission at the spinal segmental level.

Systematic reviews of massage therapy have concluded that massage is effective for subacute and chronic low back pain. Although limited in number and mixed in quality, clinical trials have shown massage is more effective than exercise, acupuncture, and self-care education in improving symptoms and function in patients with nonspecific low back pain. Several trials have suggested that the addition of massage to exercise improves outcome in patients with low back pain compared with exercise alone. These studies also suggest that the experience of the massage therapist influences outcome. The optimal number and frequency of treatments are not known.

Studies of massage for chronic neck pain are less definitive. A review of 19 trials of massage for “mechanical” neck pain found 12 were of low quality. The remaining studies of massage for neck pain as a stand-alone treatment or as part of a multimodality treatment approach were inconclusive.

Traction

Theoretically, the objective of spinal traction is to distract the vertebrae, potentially reducing protrusion of a bulging or herniated disc. Approximately 1.5 times a patient’s body weight is needed to develop distraction of the vertebral bodies. This is rarely achieved in clinical practice because patient tolerance is poor. No specific effect of traction over standard physiotherapeutic interventions was observed in adults with chronic neck pain. Conceptually, traction may be useful as an adjunct to active exercise therapy to assist in releasing muscle spasm and facilitating active therapy, but evidence for benefit is lacking. The current literature does not support or refute the effectiveness of continuous or intermittent traction for pain reduction, improved function, or global perceived effect compared with placebo traction, tablet or heat, or other conservative treatments in patients with chronic neck disorders. Only limited evidence is available to warrant the routine use of nonsurgical spinal decompression, particularly when many other well-investigated, less expensive alternatives are available.