Several speakers questioned whether the randomized clinical trial, widely considered the “gold standard” type of study for the efficacy of drugs, is really the best type of trial to examine aspects of such a heterogenous problem as chronic back pain, and whether longitudinal observational “Framingham-like” study might be more appropriate to determine what happens to patients with chronic back pain over time.
In an interview, workshop cochair Dr. Partap Khalsa, program officer of the division of intramural research at NCCAM, noted that the best clinical guidelines currently available for managing chronic low back pain are those developed jointly by the American College of Physicians and the American Pain Society. They advise clinicians to conduct a focused history and physical to help determine etiology, and only perform diagnostic imaging in selected patients with severe or progressive neurologic deficits or in whom serious underlying conditions are suspected based on the history and physical exam (Ann. Intern. Med. 2007;147:478–91).
For the 80%–90% of patients with chronic back pain for whom no specific cause can be found, the guidelines advise that physicians educate patients about appropriate self-care and prescribe acetaminophen or nonsteroidal anti-inflammatory agents as first-line therapy. For patients in whom pain persists, nonpharmacologic approaches such as exercise and spinal manipulation may be tried, along with other “interdisciplinary” approaches such as acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation therapy.
Disclosures: Dr. Khalsa and Dr. Briggs are government employees with no financial conflicts. Dr. von Korff said he received funding only from the NIH, and Dr. Franklin and Dr. Battié stated that they have no disclosures. Dr. Maixner is a cofounder, officer, and equity shareholder in Algynomics Inc.