Take a Load Off Your Back: A How-To Guide

Back pain is extremely common, affecting 84 percent of people at some point in life.¹ Risk factors for back pain include age, obesity, physically or psychologically demanding work, sedentary lifestyle, and psychological characteristics, such as anxiety and depression. Dermatologists, who routinely perform procedures in a demanding work environment, are at significant risk of developing chronic lower back pain. This pain can be severe enough to cause lost time at work: musculoskeletal disease is the leading cause of new disability claims in the US working population.² This piece discusses the highest-quality evidence from randomized trials, systematic reviews, and meta-analyses to provide strategies for preventing and treating chronic lower back pain without pharmacologic intervention.

Exercise the Options

An analysis of 21 randomized trials with more than 30,000 combined participants shows exercise and education about causes of back pain are beneficial in its primary prevention.³ Exercise may also be beneficial in the secondary prevention of back pain, based on analysis of 13 studies with more than 1,500 participants.⁴ Exercises shown to be beneficial include calisthenics focusing on balance-control, stretching, muscle endurance training, general fitness training, and abdominal muscle strength exercise. Ergonomic adjustments, such as back belts and shoe insoles, do not show benefit despite their popularity and supportive anecdotal evidence.³

Should back pain occur, non-pharmacologic therapy is often desired. Self-care is key. First, bedrest should be minimized and activity should be performed as tolerated.⁵ Educational materials are helpful.⁶ Medium-firm mattresses and conforming mattresses (i.e. foam and water) may be more helpful than firm mattresses.^7,8 Contrary to popular dogma, lumbar supports are not shown to be helpful.⁹ Other therapies that do not show benefit include interferential therapy, low-level laser therapy, ultrasound, shortwave diathermy, traction, transcutaneous electrical nerve stimulation, and percutaneous electrical nerve stimulation.¹⁰

Exercise is effective in treating chronic lower back pain, including: walking, motor control exercise, core strengthening, directional preference, aerobic exercise, general fitness exercise, flexion/extension movements, Alexander technique, yoga, Pilates, and Tai-Chi.¹¹ No exercise modality has demonstrated superiority to another. Spinal manipulation shows short-term benefit in reducing pain and improving function.¹² Acupuncture may also provide some benefit.¹³ Massage therapy provides short-term relief.¹⁴ Psychologic interventions, such as cognitive behavioral therapy,¹⁵ mind-body interventions, such as mindfulness-based stress reduction,¹⁶ and multidisciplinary rehabilitation composed of physical and psychological treatment modalities¹⁷ confer benefit.

Back to Basics

Various interventions of the mind and body can effectively prevent and treat chronic low back pain: a rampant problem in our procedurally heavy specialty. Taking the time now to use a combination of these strategies, including multiple types of exercise, can help promote a longer, painless, career.

The author has no relevant disclosures.

1. Deyo RA, Tsui-wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine. 1987;12(3):264-8.

2. Long Term Disability Claims Review. The 2014 Council for Disability Awareness. https://disabilitycanhappen.org/research-cda_ltd_claims_survey_2011/. Accessed December 23, 2018.

3. Steffens D, Maher CG, Pereira LS, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199-208.

4. Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev. 2010;(1):CD006555.

5. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493-505.

6. Burton AK, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine. 1999;24(23):2484-91.

7. Kovacs FM, Abraira V, Peña A, et al. Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet. 2003;362(9396):1599-604.

8. Bergholdt K, Fabricius RN, Bendix T. Better backs by better beds?. Spine. 2008;33(7):703-8.

9. Calmels P, Queneau P, Hamonet C, et al. Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine. 2009;34(3):215-20.

10. Maher CG. Effective physical treatment for chronic low back pain. Orthop Clin North Am. 2004;35(1):57-64.

11. Byström MG, Rasmussen-barr E, Grooten WJ. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine. 2013;38(6):E350-8.

12. Rubinstein SM, Van middelkoop M, Assendelft WJ, De boer MR, Van tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011;(2):CD008112.

13. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine. 2013;38(24):2124-38.

14. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD001929.

15. Ostelo RW, Van tulder MW, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2005;(1):CD002014.

16. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis. Ann Intern Med. 2017;166(11):799-807.

17. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ. 2015;350:h444.