Chronic low-back pain is a source of misery for millions of people worldwide. It limits their ability to work, maintain relationships or even enjoy the simple pleasures of life.
In Western medicine, opioid-based pain medication is the most common treatment for chronic low-back pain. Though these medications provide temporary relief for some individuals, their long-term efficacy is limited, and their use can create dangerous addictions.
A research team at the University of Minnesota’s Earl E. Bakken Center for Spirituality and Healing led by Gert Bronfort, D.C., Ph.D., a professor at the university’s Integrative Health and Wellbeing program, has been awarded a $14 million grant from the National Institutes of Health to investigate nondrug approaches to treat and prevent low-back pain.
The study, known as the Spinal Manipulation and Patient Self-Management for Preventing Acute to Chronic Back Pain Trial (PACBACK), is one of the largest back-pain studies funded by the NIH’s National Center for Complementary and Integrative Health. It is one of the biggest grants the Bakken Center has ever received.
Earlier this month, I spoke with Bronfort, who told me that his team, which also includes teams from the University of Washington and the University of Pittsburgh, hopes to uncover and define effective nondrug treatments for individuals suffering from chronic low-back pain.
“So many people suffer from this condition,” he said. “We want to identify ways that people can ease their pain without the use of addictive medications. We think that is possible.”
MinnPost: Why did you want to conduct a large-scale study focused on pain management techniques for low-back pain?
Gert Bronfort: Low-back pain is a common condition. It has been rated as the leading cause of disability worldwide for several years in a row. It affects up to 80 percent of the worldwide population.
MP: Does the fact that back pain affects so many people help to explain the magnitude of the opioid crisis?
GB: It is estimated that when people develop one episode of back pain, up to 20 percent will eventually become chronic sufferers, or experience recurrent episodes of back pain. That’s where most of the suffering comes from. Chronic back pain is also responsible for most of the cost of medical treatment for the condition and the source of most opioid-based pain medication prescriptions. Half of all patients who present with chronic back pain are eventually prescribed opioids. That practice is what leads to the addiction problems we are facing today.
MP: But aren’t many physicians moving away from prescribing opioids for back pain?
GB: The reality is that today most people are going to self medicate for low-back pain or they are going to be given prescription medication to treat their pain. That medication, primarily opioid-based medication, is a common form of pain-management strategy for this condition. Recent medical guidelines have suggested that patients with back pain should be offered no pharmacological options when they first present for treatment. That recommendation came out within the last year or two. But many doctors are still not following that recommendation. Often patients and medical providers revert back to giving symptomatic relief with medication. That is the reason we need to offer an active, alternative treatment for pain relief.
MP: How will your study investigate alternative pain treatment for back pain?
GB: Our study will look at the value of spinal manipulation and supportive self-management in healing back injuries and preventing future occurrences of back pain.
MP: Tell me more about those approaches.
GB: The supportive self-management approach is based on a lot of research and techniques that have been found to relieve back pain nonmedicinally. In this approach, individuals with back pain are taught how to manage their pain using alternative techniques including relaxation, developing coping mechanisms and completing specific exercises. These exercises are physical, but can also be combined with self-care techniques that include behavioral and coping strategies, lifestyle changes and pain education. Many of these strategies are developed in cooperation with psychologists.
MP: How do techniques developed by psychologists help people treat back pain?
GB: There are a number of ways this can be done. People with chronic pain can develop a fear of movement. They are afraid of re-injuring themselves and so they restrict their physical activity. Inactivity can have a negative impact on healing and actually make back pain worse. These techniques that will be taught by physical therapists or chiropractors, can help a person work through their fear of movement. Another psychological factor in back pain is the way that pain and a person’s reaction to it negatively impacts their relationships with immediate family, friends and co-workers. How is the pain affecting your ability to live a happy and healthy life? These techniques can help a person navigate those relationships and develop strategies to live a balanced life despite pain.
MP: What is spinal manipulation?
GB: Spinal manipulation is a term that refers to a variety of techniques used mostly by chiropractors but also by physical therapists and osteopaths. These techniques are commonly used in the treatment of back injuries and pain.
MP: Your study will involve treatments conducted by providers across a range of specialties. Won’t that take a great deal of coordination?
GB: This is a multidisciplinary research team. Working with a range of providers is intentional. One of the main reasons for doing a study that involves all of these professions working together, rather than pitting one professional group against another is to ultimately encourage collaboration between chiropractors, physical therapists, physicians, osteopaths and psychologists. If we want to help reduce people’s dependence on pain medications, we need to look at the whole picture of low back pain and recognize that it is a bio-psycho-social issue. We need to be open to a number of approaches that could give people the healing they so desperately need.
MP: How will your study be organized?
GB: We will divide our subjects into four groups. One group will treat their back pain with usual medical care including medication management through a primary care provider. The second group will receive spinal manipulation. The third will use supportive self-management and the fourth will use a combination of spinal manipulation and supportive self-management. This is a randomized study. There is no placebo group. Each group will be getting treatments for their pain that literature has shown to have some effect. We will be looking to discover which approach has the best results.
MP: How many individuals will you enroll in this study?
GB: The study involves approximately 1,200 patients. It will take four-to-five years to complete. We will recruit many of our subjects from the Minnesota Health systems, primarily the U of M Health System, including Fairview and a couple of other sites.
MP: Do you have any theories about what your research will uncover?
GB: We hypothesize that we will have the best outcome for our subjects with the combination of spinal manipulation and supportive self-care.
MP: This is a huge project that could impact many thousands of people. What goals do you hope to achieve from your work?
GB: Our primary goal with this study is to reduce patient suffering. We know this is a complicated condition. This would be a very important accomplishment if we could identify the most affective treatment for low-back pain. The results could be significant. If our recommendations are adopted, we may be able to significantly reduce dependence on medications. That’s why NIH is willing to spend so much money.