The Current - Many treatments for low back pain just don’t work, study suggests

Episode Date: April 3, 2025

Ann Marie Gaudon tried everything she could think of to treat debilitating back pain, but for a long time nothing worked. Now, a new study suggests very few treatments actually do work — where does that leave the millions of Canadians struggling with chronic pain?

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You might know me from my regular gig as co-host of the CBC's The Fifth Estate. You'll be hearing more from me when I fill in for Matt as he crosses the country talking to Canadians about the election. I hope you tune in, and please enjoy the current podcast. Anne Marie Gatto was working out when she suddenly felt searing pain in her lower back. It was like all the air was sucked out of my lungs. I couldn't barely stand up. I really didn't know what was happening because I'd never had a back injury before. As the

days and weeks wore on, the pain persisted. Anne Marie tried everything she could think of to treat the pain. Nothing worked. A massage made it so much worse. I went to a chiropractor who made it so much worse. Nobody knew what to do so they just did what they're trained in which was the wrong thing for me but I didn't know. She ended up waiting six weeks to get an MRI. The results showed she had a disc issues and three separate areas of nerve impingement. After that she saw a nurse practitioner and consulted with an orthopedic surgeon. Still nothing relieved her debilitating pain. I had terrible lower back pain and I had sciatica on fire down my right leg. Things became very bleak. It was extremely painful. I had a heavy limb and

I thought that I was going to be disabled for the rest of my life and I didn't know what I was going to do. Eventually Anne-Marie figured out something that worked for her and we'll get to that in a moment. But first, low back pain is the leading cause of disability worldwide. It affects millions of moment. But first, low back pain is the leading cause of disability worldwide. It affects millions of Canadians. And yet, a new comprehensive study out last month suggests few treatments for lower back pain actually work.

The study looked at 56 non-surgical treatments for acute and chronic back pain. Diana de Carvalho is one of the study's co-authors and an associate professor of clinical epidemiology at Memorial University in St. John's, Newfoundland and Labrador. Diana, good morning. Good morning. Thanks for having me. Well, it's good to have you. And there's so many people and I know so many listeners out there who have back pain.

So this is, of course, a critical issue for them. And it's kind of daunting to hear that not much works if you suffer from low back pain. Let's unpack the study itself. You're looking at 56 non-invasive treatments for low back pain. What were you looking at? Give us an idea of the scope here. Yeah and you know I'm really happy that low back pain is finally getting the attention it deserves because it's a huge problem for society and that is one of the reasons why the study was done, because it is a complicated condition that's very difficult to treat. So the whole purpose of doing this study was really to systematically

gather all the treatments that are out there studied in the literature, both pharmacological and conservative. Looking, I want to emphasize, only at one outcome, which is pain. Better or worse, it's kind of what we all tend to focus on. This is in the tightest way possible. So it's against placebo. Really the main purpose was to put this together for researchers, to help researchers with their next steps

and for clinical guideline developers to have all they need in one place. So the message that nothing seems to work is a little bit removed from what the study was intended to look at and actually what it shows because it shows and confirms what we already had a really good idea about that there are a lot of treatments out there that do effectively reduce pain and are worth trying. It does mean that we need to kind of move forward with those treatments to look at more practical ways. How do we combine those with other therapies? How can we make them better and how we can use them better in practice? So I think that's something that our author team

really wanted to clarify for folks. So what does work? Because that's the magic bullet that so many people are hanging on here. Well, and that's the thing, there isn't a magic bullet out there, right? We don't have that one thing that works. And so we go back to guideline-based care, which is again, something that we say in the paper. And there, you know, even though so many people do have back pain at some point in their life, right?

Most of those cases are non-threatening, not to mean that they're not going to be very serious, right? But I meant not serious, but like profound for the person experiencing it, as you'd be heard from our patient, right? It's very profound. But the evidence shows that when we're educated and we learn to understand the nature of back pain, you know, that it is scary, it's going to be okay, and you have to keep moving. Don't rest, don't lie down, don't get scared of movement. You know, the back is very strong, you're not going

to hurt it by moving. And so that reflex to stop and pull away and the fear that it is, you know, oh my gosh, I'm never going to be able to move again. We have to get past that. And that conservative therapies, there are lots to try exercise, you know, spine manipulation, acupuncture, anti-inflammatory medications. If your stomach can tolerate them, these are all things that have been shown to work. Um, and like our patient, a kind of illustrated, you know, not everything's going to be right for everybody, right? So and that's really where the research is starting to work.

Like we need to do a better job of getting people to the right place. But I think the good news story is that, you know, there are things out there that can that can help. And most people are going to start feeling better within four weeks. Were you also discovering some treatments that don't work? Well, you know, there are going to be things that that don't work. And, and that's the difficult thing, right? As a patient, if you try something, and if it isn't helping, you know, don't get daunted there. Stick with the guideline, guideline recommendations, and of which the best is exercise, right? Any exercise that's going to keep people moving is what you really should be focusing on. I wonder, you mentioned the fear that people have because of this debilitating pain.

As we heard from Anne-Marie, she was so worried about what her future would be like. But does that then become a compounding factor in back pain, the psychological aspect of it? It does, and it is what we see when cases do move to become chronic, so they're lasting more than four to six weeks, you know, it's become multifaceted, right, the fear and how that gets integrated into how you move and, and what

you do and how you're thinking about pain. That's where those more chronic complicated cases need to come from a very multimodal approach, which is also what the evidence supports. So that's a team approach to addressing pain management. So getting at some of the psychology of which cognitive behavioral therapy has a lot of evidence behind it. You know, how to understand and interpret pain in the best way possible from what we know from science, apart from the fear, focusing on that physical aspect, the function and activity versus the pain you're experiencing and social rates, supporting these people at work and in the community, you have to, you know, have to stay at work, you have to keep going. Because as soon as you start pulling back from that,

it really starts to compound the problem. The issue itself though, and this one I'm curious about, why is back pain so hard to treat? I think what we're seeing is that it's such a complicated, it's complicated in its individual. Right. And this is the difficult thing. The back is a highly complex anatomical and structure. Right. There's tons of structures in there and tons of different ways from where your back pain can be coming. And so that becomes really difficult. Right. You've just increased the complexity. You

think about knee pain, right? It's a very simple joint. It's kind of easier to kind of pinpoint what's going on. And it's still difficult for clinicians to manage. And so the back is just that much more complicated. And everybody is their own individual and has all these kind of nuanced factors, right? That you start to deal with.

And so the tailored approach becomes important, but also just seeing that patient and putting it in the bigger context becomes difficult because it's not so straightforward. So that brings us to the idea of prevention, which of course is all clinicians are promoting. Part of back pain is learning how to avoid it in the first place.

And you've done research on what we call sitting disease. Explain that to us. Great. So sitting, I mean, we all, most people are sitting for most of their day and we're sitting both at work and at home. And you're right. What we have found is that there are people that experience significant amounts of pain when they sit.

We actually can create it in the lab. We can show consistently that there are these people who tolerate sitting and they don't. And what it means is that we need to pay attention to it. So if you're the type of person that actually gets pain in your back when you sit, you know, and these people know who they are. They know when it happens, they know how long they can sit before it happens. It's important to listen to your body and listen to these people, right, and help them get up and move around. Our research shows that it really isn't how you're sitting but the fact that you're not moving. So yes, pay attention to a good ergonomic setup. Everyone needs to do that whether you're at work or home. It's

really important. But the most important thing that we're finding is that you need to move around. So taking movement breaks throughout the day. And really this is for everyone because even if you're not experiencing back pain with sitting, there's solid evidence out there to show that sitting and inactivity is linked to a ton of negative health outcomes. So everybody's going to benefit from limiting sitting time and getting active. And before I let you go, I just wanna know for anyone who's experienced lower back pain, they know how debilitating it can be. But what's your advice to someone listening if nothing is currently working to treat that

pain? Well, first off, we see you, right? This is definitely something that, you know, we don't want to push off to the side. This is it's an important, profound problem for people in their life. But stay active, don't rest, don't get scared of movement, and pay attention to those clinical guidelines, of which some new ones are going to be coming out soon. So there is a story there for evidence based management management. It might not be straightforward, it might feel really daunting, but we're moving in the right

direction and it's really important to, as hard as it is, to stay positive and to work on especially what you can do yourself, right, a self-management approach to dealing with that condition in your life. I've been self-managing as I've been talking to you. I realized I'm slouching. I keep sitting up straight as I listen to you. So it's already working so far. Diana, thank you so much for your time. You're welcome. Much appreciated. Diana de Carvalho is a co-author and comprehensive study on non-specific back pain and associate professor at Memorial University in clinical epidemiology. or Memorial University in clinical epidemiology.

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the anthrax killer. Available now. Stuart McGill's life work focuses on lower back pain. He's Professor Emeritus at the University of Waterloo and the Chief Scientific Officer of BackFit Pro Inc. He also runs a back pain and injury prevention clinic and is the author of Back Mechanic. Stuart joins us now, good morning Stuart. Good morning Mark.

What is your making of the findings about that not much works to treat lower back pain? I can't agree. I'm sorry. Go for it. The meta study that we just heard about looked at studies on non-specific low back pain. Correct. Have you ever heard of a study on non-specific leg pain?

And the answer is probably not, because the leg pain could come from deficient knee ligaments, a broken leg, damaged muscle, a burn or whatever. So, any study on something non-specific will only give you a null answer. So I can give you an example. Let's take posture, or you talked about sitting. Yep. Doesn't matter. If you take a group of nonspecific back pain, you will find that posture doesn't matter. However, if you subcategorize those nonspecific people on a very simple metric, those that are triggered by bending forward, doing gardening, driving a car, and those kinds of things,

versus those who are triggered by extending their spine. Now you've got two subcategories. Now rerun the study and you will find that of course posture matters. If the person bends forward and that's their trigger, they get pain every time. So we boil that right down to subcategories n equals one and we are then able to understand their specific trigger and come up with the matched specific intervention. Yeah, well tell me about that because you have a back pain injury prevention clinic.

Describe to us your assessment process when you see a client for the first time. Well, we begin with an interview. And I must say, I started this investigation in our laboratory 40 years ago. And we realized that you have to understand anatomy, biomechanics, neurology, psychology, clinical reasoning, pattern recognition, understanding the phenotypes, which came in the last few years, so that when we ask the person in the interview, tell us your story, we're doing pattern recognition. We're looking for what are the impediments that caused the 10 previous clinicians that you have seen for your back pain to fail, because if we don't understand those and address

them, we will fail too. Then we go into what is called provocative testing. We've developed a guess, a hypothesis as to what their pain pattern is, we organize then testing to purposefully create the pain. It might just be at the level of discomfort, and then we try and move the pain. So we find defensive motions, postures, loads, and activities. We find the tipping points of those, so if it's sitting, for example, we find, well, how long can the person sit before their back pain happens, or how long can they walk?

Walking might be a cure for them, or it might be a provocator. In any case, we try and create the antidote to their pain. Then we look at specific tissues. We trace different nerve roots. We might look at imaging and see if the disc bulge that the radiologist is reporting is in fact causing their specific pain. The next part is to create a plan that stops the cause. We create movement hacks for the person to move around their pain. You just said earlier you were sitting upright. Well, for some people, sitting upright will trigger their pain, and then some people sitting upright will reduce their pain. Yeah, I just have my, I always have my mother's voice in my head to tell me to stop slouching. So that's just, that's just my, my, that's my personal story. But we had, we had at the beginning those two, and we were setting up this whole conversation

where we heard from Anne-Marie Godon, and she went to you and you helped her out. And I know we don't want to get into her personal case on the radio, but for people who have had that prolonged frustration that they can't find treatment, do you find that as you go through this process that in the end you always manage to find the right treatment for an individual? No. No one shoots 100%. Okay, good to know. But what we did do, and I think Anne-Marie will confer with this, when pain is at the level

of non-specific low back pain, it's a bogeyman. The person gets slammed with an acute attack and it gives them PTSD. They never know why they got this acute attack and when is it going to hit them next? But after we do the assessment, they are highly aware of what the pain trigger was and now they've transformed the bogeyman of non-specific back pain into something that is now known and it becomes their tutor. Oh, I broke that new rule, Now I understand my pain, and it's not quite as troublesome, shall we say. But what we did do was we followed up with every patient we ever saw in the history of our clinic.

We subcategorized them, and we know exactly our clinical score. For example, say a person had that flexion-triggered pain doing gardening and whatnot, or bending forward and lifting a box and they get an acute attack. In a two-year follow-up, 50% of them, after they did the intervention that we gave them, said, we are now fine, we have no further concerns. The rest of the people will take about 10 years to, not that they have a great risk of triggering again, but if they don't follow the rules, they may trigger. And that adaptation will take about 10 years. But remember the person who I said gets pain when they extend. Usually an older person with a more arthritic or stenotic condition in their back, after

the two years, 80% of them said, we, following this intervention, have no issue anymore. But here's an interesting statistic. If the person fell into the category that they've tried everything, they've been to the chiropractor, the psychologist, the physical therapist, they've had a surgical consult, the only option left for you is surgery. If that's your subcategory, if they follow the program we gave them, after two years, 95% of them avoided surgery and were glad that they did. So is surgery not needed?

Of course it is. Surgeons are at their very best for very specific conditions like heavy stenosis, etc. So my point is, once we subcategorize their pain, we know with some precision what the efficacy is going to be and how long it will take. But no, some people cannot be fixed, sadly. But it's a very, very small percentage. If someone, and I've only got 30 seconds here, so just give them a ray of hope, but if someone's listening right now has tried absolutely everything

to get rid of their back pain, what's your advice for them? I wrote a book called Back Mechanic to solve exactly that issue. Keep spine power low. That's force times velocity. If you're lifting something heavy, don't move your back, use your hips.

If you're moving your spine quickly, playing golf, use lower hips. If you're moving your spine quickly, playing golf, use lower forces. If you don't sit too long, would be another one. Our studies on groups like police and firefighters showed that those who have sufficient fitness, not maximum fitness, are more resilient. The ones who are in the gym training to extremes are getting more hurt than those training for moderation. Eat like an adult, to quote my friend Dan John, move well, move often, as Dr. DiCavello said. But get an assessment, a thorough assessment, know with precision your specific pain triggers and mechanism,

and address it with a specific intervention. Stuart, thank you so much. You're offering hope. My pleasure. Thanks for all you do at the CBC, Mark. Thank you so much. Stuart McGill is Chief Scientific Officer of BackFit Pro, also Professor Emeritus at the University of Waterloo and the author of BackFit Pro, also Professor Emeritus at the University of Waterloo

and the author of Back Mechanic.