Most Treatments for Low Back Pain Don’t Work

By Crystal Lindell

While I’ve struggled with relatively mild lower back pain for years now, a few months ago I threw my back out for the first time. I literally could not get out of bed on my own, and I spent almost a week on the couch recovering while my lower back spasmed. 

It was horrible, and even my usual pain relief methods and doses of pain meds did not help much. In the end, for me, it was mostly just time and rest that seemed to help the most. 

Now a new study confirms just how difficult it is to treat low back pain. 

In fact, only about 10 percent of treatments for low back pain actually work, according to new research published this week in the journal BMJ Evidence-Based Medicine. 

The study by an international team of researchers looked at 301 placebo-controlled clinical trials for 56 different treatments for low back pain. The team found that most non-surgical and non-interventional treatments did not work. Those that did work provided only small analgesic effects better than a placebo.

Specifically, they found that NSAIDs were the only treatment that worked for acute low back pain, while five treatments for chronic low back pain provided relief: exercise, spinal manipulative therapy (chiropractic), taping, antidepressants, and transient receptor potential vanilloid 1 agonists, which are topical patches like Qutenza (capsaicin).  

As for the treatments that did not work, the researchers found that three treatments for acute low back pain – exercise, glucocorticoid injections, and paracetamol (acetaminophen) – and two treatments for chronic low back pain (antibiotics and anaesthetic drugs) were ineffective. 

They didn’t have enough good quality evidence for the remaining treatments to determine if they worked or not. 

For acute low back pain, 10 non-pharmacological treatments had “low to very low certainty evidence” that they actually worked, including: acupuncture, behavioral health education, extracorporeal shockwave, heat, laser and light therapy, massage, mobilization, osteopathic, spinal manipulative therapy, and transcutaneous electrical nerve stimulation (TENS). 

They also found that 10 pharmacological treatments had inconclusive evidence about their effectiveness for acute low back pain, including: cannabinoids, colchicine, immunoglobulin, muscle relaxants, muscle relaxants + NSAIDs, nucleoside, opioids, ozone injections, pyrazolone derivatives, and topical rubefacients.

For chronic low back pain, over three dozen treatments had inconclusive evidence to support their efficacy, which included everything from bee venom and TENS to dry cupping and muscle relaxants.

The bottom line is that there’s not much evidence to support the use of many treatments that are commonly prescribed and promoted for lower back pain — even the ones recommended in medical guidelines.

“Our review did not find reliable evidence of large effects for any of the included treatments,” researchers concluded. “There are also common treatments for which no placebo-controlled trials have been conducted despite being commonly recommended in clinical practice guidelines.”

The study ends as many often do, with a plea for more high-quality evidence to give patients and doctors real choices and effective options for treating back pain. 

“While we would like to provide more certain recommendations for where to invest and disinvest in treatments, it is not possible at this time,” researchers said.

FDA Approves Capsaicin Patch as Treatment for Diabetic Neuropathy

By Pat Anson, PNN Editor

Millions of patients with diabetic peripheral neuropathy live with burning or stinging pain in their hands and feet. In what could be called a case of fighting fire with fire, the U.S. Food and Drug Administration has approved the first use of a medicated patch made with capsaicin – the spicy substance that makes chili peppers hot – as a treatment for diabetic neuropathy.

The Qutenza skin patch is made by Grünenthal and contains 8% capsaicin, which acts on pain receptors in the skin by desensitizing and numbing nerve endings.

“Pain associated with diabetic neuropathy is an extremely challenging condition to diagnose, treat and manage effectively, which has a significant quality of life impact for many patients,” said David Simpson, MD, a Professor of Neurology at the Icahn School of Medicine. “In addition, patients are dissatisfied with unresolved pain and the side effects associated with current systemic treatments.”

A 2015 study found that Qutenza worked faster than pregabalin (Lyrica) in treating neuropathic pain, providing relief in 7.5 days, compared to an average of 36 days in patients taking pregabalin. Patients who used Qutenza were also more satisfied with their treatment and had fewer side effects.

That same year the European Commission approved Qutenza as a treatment for diabetic neuropathy, but it took another five years for the FDA to give its approval for the same condition. The patch was initially approved by the FDA in 2009 for treating post-herpetic neuralgia, a complication from shingles.

“Painful diabetic peripheral neuropathy has a significant impact on the day-to-day lives of millions of individuals, and we believe Qutenza can be a much-needed non-opioid treatment option for these patients,” Jan Adams, Grünenthal’s Chief Scientific Officer, said in a statement. “This expanded indication of Qutenza in the U.S. is an exciting milestone in our efforts to make Qutenza available to even more patients in need worldwide.”  

A big catch is that the patch shouldn’t be applied at home and should only be used sparingly. According to its warning label, Qutenza should be applied by a doctor or healthcare professional, who should be wearing a face mask and gloves to protect themselves in a well-ventilated area. Up to four patches can be applied on the feet for up to 30 minutes, a procedure that can be repeated every three months. The most common side effects are redness, itching and irritation of the skin where the patch is applied.

Qutenza has gotten mixed reviews from patients, who warned that capsaicin can cause painful burning sensations.

“Qutenza really does work. I did have very intense burning,” a patient posted in a review on Drugs.com. “The pain can be mind blowing but it does subside and a cool fan helps. Don't let your pets near the area as it will burn them. I have had multiple Qutenza and… it lasts up to 3 months plus. Don't apply yourselves. Use a health professional as it does burn.”

“Although I was informed about this treatment and how your body might react to it, my case spiraled out of hands,” another patient wrote. “The medics had to call a team to manage my situation. The pain was so much that without a shred of doubt words simply can not explain.”

Diabetic neuropathy is a progressive and debilitating complication of diabetes that affects more than 5 million Americans. Patients typically experience numbness, tingling or stabbing sensations in their hands and feet. More severe cases can result in foot ulcers, amputations and other complications.