Managing back pain and osteoarthritis without paracetamolBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1352 (Published 31 March 2015) Cite this as: BMJ 2015;350:h1352
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The lack of efficacy, and growing evidence of potential harms of Paracetamol, together with increasing strictures over prescribing NSAIDs and opioids, now leaves doctors with few tools to help patients with extremely common painful and disabling conditions.
Exercise is undoubtedly helpful and encourages self-management but it is limited in its scope. The effect wanes after stopping exercise, and its applicability is limited to those at the moderate end of the spectrum.
As a GP who uses osteopathy in NHS general practice to treat patients with spinal pain (and some other joint pains), I can testify to the extremely high levels of sustained patient benefit achieved. Leading to reduced rates of analgesic prescribing, repeated consultations, sickness absences and referrals to secondary care, patients consistently report very high levels of satisfaction and ongoing benefit.
Osteopathic manipulation is recommended as first line treatment in NICE 2009 guidelines. It is effective and, despite overstated claims to the contrary, in the right hands it is much safer than many currently accepted treatments - including NSAIDs.
Manipulation techniques vary between osteopaths, physiotherapists and chiropractors, so the skills of individual therapists do matter.
Alexander Technique is another physical treatment for spinal pain, also recommended first line in the NICE 2009 Guidelines (as part of 'exercise' but buried in the small print).
The 2008 ATEAM trial showed high quality evidence that Alexander technique conferred the largest benefits yet of any treatment for back pain; there were no harms associated with treatment and, unlike any other treatment, the benefits were actually increased one year later.
Both trialled in general practice settings, osteopathy and Alexander Technique could provide major benefits to patients with back pain, over and above current treatments. Given the added benefits of secondary cost savings to the NHS and to workforce absence, osteopathy and Alexander Technique should be modelled for incorporation into NHS primary care.
Competing interests: No competing interests
It is now nearly 7 years since the BMJ published a large RCT* showing substantial long term benefit to patients with chronic or recurring low back pain from a course of 24 individual Alexander Technique lessons (the average number of days in pain fell from 21 per month to 3 per month, with the results better at 1 year than they were at 3 months). A recent pilot trial in knee osteoarthritis demonstrated considerable benefit from 1:1 Alexander Technique lessons, see also **,and a RCT is under way in the north of England on this topic. How much longer do patients have to wait for this method to appear in the NICE guidelines for chronic back pain and OA?
**Osteoarthritis and Cartilage 2013; 21 (Suppl): S106.
Competing interests: I am a medical doctor and a teacher of the Alexander Technique
Re: Managing back pain and osteoarthritis without paracetamol, Physical treatments (such as osteopathy) are the way forwards
Whilst suggesting that physical treatments are the way forward in managing back pain and osteoarthritis, as Mallen and Hay have said, timely access to NHS physiotherapy services for the expert management musculoskeletal complaints is increasingly difficult to achieve (1). This in part explains why some patients who are able to afford to do so seek care for their musculoskeletal pain with practitioners in the independent sector.
There are thousands of state regulated registered osteopaths and chiropractors working outside of the NHS who expertise provides a valuable alternative musculoskeletal pain service. Their management of significant numbers of such patients helps to reduce the burden of patients who would otherwise be sitting in GP surgeries; some of whom would otherwise eventually be referred onto more expensive secondary care.
In osteopathic practice the times allocated for follow up appointments are in the range of 20-30 minutes per session (2). Thus pragmatically osteopaths are able to offer not only manual physical interventions such as spinal manipulation, spinal joint mobilisation and massage as standard therapeutic modalities, but are in the enviable position to have the time to provide patients specific exercises that are sensitive and appropriate to the stage of improvement in the individual patients overall outcome. The appropriateness of timing and staging of exercise in relation to the history of back pain appears to be important in its therapeutic effectiveness (3).
Thus this type of approach adopted by osteopaths I would tentatively suggest is perhaps more psycho-educationally conducive to patient’s short to medium term symptomatic and functional improvement and to longer-term compliance for adopting prophylactic exercise regimes.
There are also increasing levels of evidence from randomised controlled trials supporting the premise that specifically osteopathic interventions are useful in patients with back pain (4). However in clinical practice to also improve the benefit/risk ratio of their treatment most osteopaths use massage like soft tissue techniques (5), which have also been shown to have value in the management of back pain (6), more often than they actually use spinal manipulation procedures. A subtle but potentially significant difference that should not to be overlooked when referring patients for safe physical treatment approaches (7).
1) Mallen C, Hay E. Managing back pain and osteoarthritis without paracetamol Physical treatments are the way forward. BMJ 2015;350:h1352
2) Sanderson M. Should chiropractic and osteopathy be purchased for the treatment of back pain in Cambridge and Huntingdon? British Osteopathic Journal 1995; XVII: 9-29.
3) Hidalgo B, Detrembleur C, Hall T et al. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. Journal of Manual and Manipulative Therapy 2014;22 (2):59-74.
4) Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014 Aug 30;15:286.
5) General Osteopathic Council. Snapshot survey 2001 Results 2001.
6) Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International Journal of General Medicine 2013:6;733–741.
7) Ernst E. Osteopathy how different is it to chiropractic? www.Pulsetoday.co.uk/comment-blogs/-/blogs/12958417/osteopathy-how-diffe...
Competing interests: I am an osteopath working in the private healthcare sector, and have also previously worked in the NHS in an occupational health role.
I had the misfortune to develop severe sciatica without warning or any obvious precipitating cause 2 years ago. At its worst, no oral analgesia made any real inroads into the excruciating pain down my left leg. I do however count myself lucky that as the discomfort has lessened paracetamol does seem to help. Keeping active with back pain is a very laudable aim but I understand now why many of my own patients find it so difficult to rehabilitate from back problems.
I was an active 56 year old before my sciatica developed. I was incapable of any activity when the pain was at its height. I went from carrying clubs and playing golf 2-3 times a week to being unable to even get dressed unaided. The only exercise I could do when the pain relented a little was to swim. Two years on, I continue with physiotherapy every 2-3 weeks which is still bringing improvement. Swimming and private physiotherapy are costly. I also learnt very rapidly that if you are not moving much you do not burn any calories and so I reduced my calorie intake significantly in order to keep my weight down. If we are going to promote physical activity to manage back pain; infrastructure and significant support will need to be in place to stand any chance of making a difference.
Competing interests: No competing interests
I have practised modern medicine for the last 46 years, out of which 30 years was in the armed forces.
Since the last 8 years I was associated with the above ayurvedic medical college and I was amazed to see the excellent results of their management of back ache and joint pains with out any oral medication!
They know what they are doing. Detailed history taking and minimal investigation to rule out malignancy and specific infections treatment is decided on each patient very professionally.
Minimal manipulation and application of external medication is the basic principle. No paracetamol/NSAID.
Their treatment is very effective and in gives excellent relief to patients with a couple of weeks of inpatient treatment.
And it is NOT expensive.
Competing interests: Management of trauma and geriatric cases. Back ache and pain in various joints-the ayurvedic way.
Your article at last focuses on a field where genuinely integrated medicine can play an important part in improving health, and can also save the NHS thousands of pounds. My own story illustrates this perfectly.
In 2001, when living in the south of England, I fell downstairs and sprained both ankles badly. This triggered arthritis in my right hip. (Was this waiting to happen after two years of high-dose tamoxifen for breast cancer? I shall never know.) I asked to be referred to an orthopaedic surgeon. The waiting list on the NHS was around a year, and I was in considerable discomfort, so I decided to go privately, and was referred by my GP. The orthopaedic consultant looked at my X-ray and said: 'Well, yes, you do have arthritis in that hip, but you won't need an operation for about five years.' 'Fine,' said I, 'but what do I do now?'
'Go to the health food shop', he replied, 'and get yourself some glucosamine sulphate'. 'Right', I replied, ' and what about cod liver oil, yoga, cycling, osteopathy?' 'Yes, go ahead with all those', said he. He even copied his letter sent to my GP to my osteopath, who had been treating me for lower back pain, recommending osteopathy as the appropriate treatment. So I followed his advice, and after three months the pain had gone. No suggestion whatever of pain-killers.
In 2003 my husband and I moved to Scotland to join family members. In the same year the BMJ published a 'POEM' concluding that glucosamine sulphate was effective in treating osteoarthritis, (1) and it was then permitted to be prescribed on the NHS, so I asked my GP if he would do so. He obliged. Since then I have continued more or less pain-free, and the NHS has been saved the considerable expense of a hip replacement. The odd twinge has been sorted by the addition of chondroitin (not available on the NHS), herbal pills from my Chinese acupuncturist (2) (who has been very helpful in alleviating the pain and swelling of fibrotic lumps in my breast and axilla caused by radiotherapy in 1987), the avoidance of citrus fruits, losing a bit of weight and attention to diet, and more recently on a flare-up, treatment from a chiropractor. I have also been helped by physiotherapy (on the NHS), and I have benefited recently from free yoga classes arranged specially for carers at a local centre. (Since 2007 when my husband had a stroke I have been his main carer.)
However, when recently I sprained my knee after doing some gardening and was in considerable pain, I visited my GP again (not my usual doctor: it was an emergency visit since I was in such discomfort), who prescribed enough paracetamol and ibuprofen to last me for the rest of my life (I am 83), and suggested using an elastic bandage. After taking two doses of pain-killers without any effect I went to my Chinese acupuncturist, who sold me some herbal plasters. They did the trick within a week. I also had a session with my chiropractor, since the arthritis was now affecting both knees. A month later I am pain-free and the swelling in my knees has subsided.
For me the moral is: use all available remedies, whether orthodox or complementary. For the healthcare profession the moral should surely be the same: but unfortunately useful interventions are not always available on the NHS. However, if they were, the NHS would save a lot of money. I can afford a few complementary treatments, but many people can't. My original orthopaedic surgeon did give me very helpful advice: would that all doctors did the same.
Edinburgh EH3 9LL
1. POEM (Patient-Oriented Evidence that Matters): Glucosamine improves joint mobility for 1 in 5 patients with osteoarthritis. BMJ 2003: 327 (6 December), doi 10.1136/bmj.327.7427,0-1.
2. The ingredients were: retinervus luffae fructus, radix scrophlariae, radix angelicae, radix codonpsis, flos carthami.
Competing interests: No competing interests