Innovative treatments for back pain
To review innovative treatments of back pain, we must first determine the need for such innovation. This is an important matter—sooner or later innovation will be needed at other stages of the cycle–innovative methods of dissemination,4 promotion19 or participant recruitment,55 innovative approaches to quality control or clinician adherence. In such cases, the treatment may be excellent and the focus of innovation shifts to optimising the impact of the treatment on public health.
Do we still have a problem with back pain? The 1990 Global Burden of Disease study sought to quantify the burden of nonfatal health outcomes, using a metric that captured years of life lived with “less than ideal health,” termed “years of life lived with disability” (YLD).91 That study identified low back pain as the single most burdensome nonfatal condition globally, and one of the 4 most burdensome nonfatal conditions in every country or region for which data were available. This startling discovery presumably triggered industry and government support to solve what was clearly a massive public health problem. The 2011 Global Burden of Disease study may have been expected to illuminate the gains that had been made over the previous 20 years. Unfortunately, however, low back pain remained the most burdensome nonfatal condition, by a larger margin than it was 20 years earlier, accounting for 11% of the total YLD (83 million YLD). Low back pain, affecting 1 in 10 people, was 6 times as prevalent as angina and twice as prevalent as depression.116 The 2015 update categorized back and neck pain together, but showed little or no change in prevalence or burden.
This disappointing situation is not for want of trying. There are many treatments already available. Treatment approaches have often been based on the work of a particularly prominent or charismatic clinician (or perhaps entrepreneur). In physiotherapy for example, such approaches have tended to be named after the “guru” who developed them–for example the Maitland,69 McKenzie,74 or Mulligan42 approaches. Other treatments have been developed on the basis of empirical research that identified behavioural differences between those who have back pain and those who do not–for example “motor control” approaches.111 Although such treatments are often innovative, almost without exception they are vigorously promoted and widely adopted, sometimes to the extent of institutes and even notional “universities” dedicated to their promotion, before their clinical effects are tested with scientific methods. Such treatments occasionally have sensible theoretical justification, but their proponents are often too conflicted to test them with any rigour. This is not to say “nothing is effective,” but to highlight that innovative treatments for back pain do exist, but popularity or unsubstantiated claims of their inventors or proponents, were not considered worthwhile reasons for inclusion in this review.
This is also not a review of “effective treatments for back pain.” If one were to review “effective” treatments for back pain, the picture would be rather large but perhaps somewhat underwhelming. There is now a massive body of randomized controlled trials (RCTs), systematic reviews, and meta-analyses on treatments for back pain.