WASHINGTON -- In a major departure from traditional practice, federal health officials said yesterday that the expensive tests and therapies typically used to diagnose and treat lower back pain are largely useless, and instead recommended over-the-counter pain medications, chiropractic and low-stress exercise, such as swimming or walking.
For most patients, symptoms will disappear on their own within a month, they said.
Acute lower back problems -- pain or discomfort in the lower back, or pain and numbness that moves down the leg (sciatica) -- is a sometimes debilitating condition suffered at some point by almost everyone.
In fact, after the common cold, it is the leading reason why people see their primary care physicians, according to the federal government.
Back pain can occur for no apparent reason at any point on the spine, but most commonly crops up in the lower back region because it bears the majority of the body's weight.
Lower back pain can severely restrict an individual's activities, including the ability to work -- sometimes for weeks. In 1990, more than $20 billion in direct medical costs was spent on the condition, mostly for diagnostic tests. The total annual cost -- including lost productivity -- is estimated at $50 billion.
The practice guidelines were compiled by a panel of medical experts who reviewed nearly 4,000 studies. The Agency for Health Care Policy and Research released the recommendations, which are expected to be regarded as the standard of care.
The panel did not address chronic lower back problems, which are the subject of continuing studies. But it stressed that people with long-term problems represent fewer than 5 percent of those afflicted with lower back pain. This group may or may not include people with disk problems depending on the extent or severity of their symptoms.
The guidelines will provide "new hope to those who are confused about the myriad of approaches to acute low back problems," said Dr. Stanley J. Bigos, chairman of the panel and professor of orthopedic surgery at the University of Washington School of Medicine in Seattle.
The panel said the early use of tests such as X-rays, computed tomography and magnetic resonance imaging should be discouraged unless symptoms indicate more serious underlying conditions, such as fractures, tumors or spinal nerve root problems.
Also, the usual therapies -- extended bed rest, muscle relaxants and surgery -- can be needless and, in some cases, harmful, the panel said.
Resting in bed for more than four days "can weaken muscles and bones, and delay recovery," the panel said.
In the first three months of symptoms, surgery is only recommended for those with evidence of serious spinal problems, or certain leg symptoms that result from nerve conditions, dislocations or fractures, the panel said. Surgery appears to benefit only about one in 100 individuals with acute low-back pain, the group said. Instead, the group said the use of acetaminophen and nonsteroidal anti-inflammatory drugs is safe and effective, as well as walking, swimming or biking, which helps maintain and build tolerance to physical activity.
Chiropractic, which uses spinal manipulation to ease pain, was also found to be helpful, especially in the first four weeks of the onset of pain, the panel said.
The recommendations were a significant validation to the century-old discipline of chiropractic, as well as a rebuff to surgeons.
For many years, chiropractic was an object of criticism and scorn from the medical establishment, despite growing widespread consumer support. But in recent years, it has begun to enjoy increasing credibility within mainstream medicine.
Dr. Lowry Morton, chairman of the American Chiropractic Association, noted that spinal manipulation is a drug-free, nonsurgical, low-cost form of relief. He said he hoped the new guidelines would encourage managed care health plans and health maintenance organizations to include chiropractic within its coverage.