Louise Hailey and Jennifer Bridle
Lifestyle Products, Devices and Supports for Low Back Pain
Although we know that for the majority people with low back pain, symptoms will improve rapidly. However, at a year, a third of the people still report persistent symptoms. For some of these people, low back pain may recur, becoming either an episodic or even a chronic problem.1 Treating back pain can be very costly and often includes overemployment of treatments that are not advised within current clinical guidelines.2
Recently published clinical guidelines1,3 suggest that most back pain does not need referral to specialist services and is likely to improve with primary care management. Understandably, many back pain sufferers become frustrated after experiencing treatments that do not help and often want to find their own solutions to their low back pain. They may choose to seek out, and pay for, self-help treatments or products, for example, back supports or a new mattress. These could be used to either treat their current episode of back pain or attempt to prevent future episodes of pain. Furthermore, many healthcare practitioners recommend products to their patients.
Cost-effectiveness of non-invasive and non-pharmacological treatment interventions for low back pain is poorly understood.4 The most recent systematic reviews by Chou et al.5,6 of non-pharmacologic interventions for lower back pain did not include or identify evidence for lifestyle products, such as specialist seating or furniture. Lifestyle products and devices for low back pain are not often supplied by healthcare services but purchased by the back pain sufferers themselves, often at high cost to the individual. These types of products are widely available, and often sweeping claims are made regarding the health benefits with what appears to be little more than anecdotal evidence. Given that most products and devices need to be purchased by patients, care needs to be taken when advising them on the role of lifestyle products and devices. One cannot simply assume that the use of a product or device equals benefit, and, further, it may even lead to harm. A negative health outcome can result from either poor medical advice on these products/devices or with their use. Therefore, in providing inappropriate advice a healthcare practitioner may inadvertently contribute to the ongoing problem of low back pain and pain related disability. For example, if the product or device does not promote wellness but leads to restricted movement and activity, by reinforcing unhelpful thinking, such as spinal mal-alignment or instability, the patient may be left in worse condition physically and psychologically.
There is no evidence of medical harm done with use of lifestyle products and devices used to treat low back pain. On the contrary, they may promote health, well being and independence, but should be part of a package of care aimed at empowering a person with back pain to realize they can achieve a “normal” lifestyle rather than live in fear of a progressive degenerative condition.
This chapter will consider the commonly used lifestyle products, devices and supports that are used by people with the aim of helping or preventing low back pain and the evidence for their use. The list of products, devices and supports is by no means exhaustive, and a brief Internet search or scan of a magazine’s advertisements would reveal even more products.
People believe that certain lifestyle products are likely to have a positive effect on back pain, and they may turn to healthcare professionals for advice on these products. The literature tells us that most back pain episodes will improve regardless of the intervention, but back pain sufferers may credit their improvement to the use of lifestyle products, such as mattresses.
Mattresses, Pillows and Sleep Surfaces
Accurate data is difficult to obtain, but it is estimated three million mattresses and beds are sold in the UK every year. It is estimated that up to 30% of mattress sales are to people trying to alleviate their back pain. About 35% of those sold do not meet the expectations of the purchaser.7 Authors have examined the evidence for using mattresses, pillows and sleep surfaces as interventions for low back pain, but there is no high quality evidence currently available to support advice to use a particular type of mattress, pillow or sleep surface for helping treat low-back pain.8-10
Desks, Seating and Other Furniture
A variety desks, seating and furniture are marketed and sold with the promise that they will help prevent low back pain. These products appear to have been developed in the 1990’s largely on theoretical models surrounding back pain with the intention to maintain the “correct” spinal posture. A current trend is the use of sit-stand desks. In general, these products are aimed at helping back pain and may in fact do so, but they often cost the purchaser in terms of financial outlay and long-term well being. If the purchaser assumes products are treating their low back pain, it may lead to dependency and increase the risk of developing chronic low back pain.
There is no evidence to support using specific types of desks, seating or furniture aimed at helping low back pain. The best evidence currently, in terms of lifestyle, is for people to remain active. Therefore, it would make sense to advise patients with low back pain to minimize time spent in any one position without moving or exercising.
Overall, the evidence supporting the use lifestyle products for low back pain is poor. There is no high quality evidence to support the use of lifestyle products for low back pain.
Patients often ask for advice about devices to help with management of their back pain. Whilst the literature states that both an active lifestyle and time will improve back pain, media and marketing campaigns promote the use of various devices for a faster recovery. This list of devices is by no means exhaustive.
Magnets have been used in the treatment of pain for a number of years and they have become increasingly popular with the public, with a large variety of magnetic devices now available. Media campaigns have supported the use of this alternative therapy in pain; worldwide sales of billions of dollars are reported.11 Clinicians have remained skeptical regarding their use in the management of pain. It has been hypothesized that magnetic fields have an effect on biological materials.12 There have been claims that magnets can restore the magnetic balance, increase the calcium ion migration speed to accelerate bone and tissue healing, increase circulation and have a positive effect on hormone release. It has also been suggested that pulsed oscillating electromagnetic fields can relieve pain and inflammation.13 Whilst the physiology of these magnetic fields have been explained in the literature,12,13 there have been few high quality studies regarding the efficacy of magnetic fields in pain. There is much anecdotal evidence in medical practice of patients reporting a significant improvement in pain, but, because there is a lack of high quality evidence for the use of magnets, it is difficult to recommend them as a treatment for low back pain.
Acupuncture and acupressure has been suggested to help with low back pain, and there is an abundance of literature assessing the efficacy of these treatments.14,15 The American college of Physicians,16 American Pain society16 and the National Institute for Health Care and Excellence (NICE)17 have previously supported the use of acupuncture for low back pain. In the most recent review of the evidence acupuncture was considered is a relatively safe intervention, but it lacked treatment effect when compared to sham intervention. Acupuncture is no longer recommended by NICE for low back pain.18
Acupressure has been used in traditional Chinese medicine alongside acupuncture for centuries.19 It is thought to reduce pain using the same meridian theory as traditional Chinese acupuncture through the action of pressure from fingertips along meridians, or at certain acupuncture points. The main benefit of acupressure is that it is a non-invasive treatment, which enables patients with contraindications to acupuncture to access pain relieving modalities.19Acupressure mats are designed to work in the same way as traditional acupressure. It is claimed that they promote the release of endorphins, which relaxes the mind and body. It has also been suggested that these mats can be used for trigger points within muscles to help reduce muscle tension and, therefore, pain. There are a wide variety of acupressure mats marketed for pain relief, but it is difficult to recommend these devices because of the significant cost and poor quality evidence supporting their use.
Massage is a well-recognized treatment for back pain with most therapists offering this modality to patients at some point for the management of their pain. Massage techniques aim to improve physiological outcomes by releasing endorphins, enabling relaxation and breaking the cycle of pain.20 There has been a large volume of research on massage, with authors examining massage against both active and inactive controls; most research is methodologically flawed.20 Massage for back pain can be suggested as an adjunct to other treatments, such as exercise and encouraging patients to remain active. With countless hand held massage tools, mattresses and chairs available on the market, patients could use these alongside a treatment package from a qualified therapist. The low quality research available does not support the use of these tools in isolation.
The benefits of heat and warmth have long been associated with the reduction in pain. Thermal devices claim to induce relaxation and, therefore, reduce muscle spasm and modify pain pathways. Clinicians often recommend heat treatment, but the quality of research behind this treatment is not robust.21 Whilst there has been an abundance of research that has looked at the use of heat in comparison to other modalities, it can be concluded that use in isolation cannot be recommended. Heat may be beneficial in the short term, however, not in long term management of back pain.22
Please refer to the chapter “TENS for Low Back Pain.”
Overall, the evidence available for use of devices by patients is poor. Whilst some devices may be beneficial for use alongside a tailored therapeutic intervention, they cannot be recommended for use in isolation.
Along with devices, clinicians are often asked for an opinion regarding the use of supports for low back pain. The evidence is clear that the best advice for low back pain is to undertake an active lifestyle. Nevertheless, due largely to media and marketing programs, patients are now exposed to these aids and supports and are willing to try them to reduce pain faster.
Clinicians and patients often discuss the use of these for managing low back pain. They may claim to improve posture and prevent slouching while sitting along with speeding up recovery by enabling the back to rest immediately after injury. However, they are commonly described as detrimental to a patient’s recovery from back pain as they reduce range of motion as well as prevent muscle activation, which leads to weakness and increased disability. NICE18 have recently stated that the use of lumbar supports, braces and corsets should not be recommended to patients as most studies suggest that there is insufficient evidence to demonstrate the efficacy of these appliances in the management of back pain.22 Braces and supports may still be used in some conditions such as scoliosis and pregnancy related low back pain; however, for non-specific spinal pain, there is limited evidence to suggest that clinicians should be recommending them.
Walking aids have been used for decades to help reduce pain and improve mobility. Their uses range from an aid for balance and increased confidence, off loading weight bearing pressure on a painful area and promoting user independence. Whilst there is little evidence available for the effects of walking aids when used for back pain, they could be implemented following clinical assessment on whether the walking aid would improve the patient’s function or safety.
There is widespread use of orthotics in the treatment of low back pain with a high rate of patient compliance and satisfaction, with most studies suggesting that they improve both pain and function.23 There is a huge market for the use of both off-the-shelf and custom-made orthotics, and a vast amount of money is spent on these devices each year. Whilst the literature has stated that there is not enough evidence at present to recommend the use of orthotics in back pain, there is a number of studies that have discussed the biomechanical advantages of orthotics.23 The aim of an orthotic is to realign the feet and subsequently improve a patient’s posture and, therefore, pain. Whilst literature has addressed the biomechanical advantages of orthotics the research regarding the effect on pain and function of a patient suffering with back pain is limited by studies of poor methodological quality.18
Over the past decade, many claims have been made that rocker sole shoes will decrease the incidence of back pain. They have also been marketed as decreasing back pain in patients that have been suffering with chronic low back pain. There is plenty of anecdotal evidence to suggest that the rocker sole shoes work, with patients regularly reporting an increase in function and decrease in pain since wearing them. However, recent literature has stated that there is no difference in flat-soled shoes compared with rocker-soled shoes in the treatment and management of back pain.24 NICE has recently agreed that there is no evidence to suggest that rocker soled shoes are of any benefit to patients with back pain.18
While there are a number of studies that suggest that certain supports may give benefit to a patient’s pain and recovery following an episode of back pain, the majority of evidence has been from single small studies. It has also been suggested that, while some of these studies claimed a benefit, this was a benefit in function rather than in pain reduction.18 Therefore, it is difficult to recommend supports to patients in an attempt to help with their pain and function.
- New lifestyle products, devices and supports aimed at improving low back pain will continue to emerge on the market, and some may lead to a shift in efforts to prevent chronic low back pain.
- More research is needed to understand the safety and efficacy of lifestyle products, devices and supports when used to treat or prevent low back pain.
- Any new trials assessing lifestyle products, devices and supports for low back pain need to be high quality studies that evaluate the use of any product in real world settings, with the aim to increase high-value care for treating low back pain.
PEARLS AND PITFALLS
- Devices and products developed for low back pain often evolve from theories on the pathophysiology of pain, and they are marketed on the back of poorly understood theories and myths, rather than sound trials and evidence.25
- Non-pharmacologic interventions and devices do not need to undergo the same rigorous processes required for pharmaceuticals to prove safety or efficacy. These devices or interventions should be examined in more detail before being made available.25,26
- Whilst some of the products, devices and supports that are readily available on the market may be valid treatments for low back pain, studies demonstrating their efficacy are needed to substantiate their use and improve quality of care for low back pain sufferers.25
- Given low back pain is currently the leading cause of disability worldwide, clinicians should always base treatment recommendations on sound evidence and patient preferences that will minimize harm and costs.3,27
- In general, there is little high quality evidence available for any non-pharmacologic interventions for low back pain and in particular lifestyle products, devices and supports. Where trials do exist for direct comparisons of the interventions, these show small if any differences.3
- With the challenges facing healthcare in terms of resources, one should focus on delivering high-value evidence based healthcare.27,28
- NICE. Low back pain and sciatica in over 16s. QS155. London: National Institute for Health and Care Excellence; 2017.
- Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-1581.
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
- Andronis L, Kinghorn P, Qiao S, Whitehurst DG, Durrell S, McLeod H. Cost-effectiveness of non-invasive and non-pharmacological interventions for low back pain: a systematic literature review. Appl Health Econ Health Policy. 2017:15(2):173-201.
- Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(7):493-505.
- Chou R, Deyo R, Friedly J, et al. Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(7):480-492.
- Ancell B. How sleep surfaces affect our backs. Positive Health. 2000;48:44-46.
- Donoghue E, Wasiak J. Beds and mattresses for back pain. Transport Accident Commission & Worksafe Victoria; 2012.
- Mattresses for Chronic Back or Neck Pain: A Review of the Clinical Effectiveness and Guidelines. Canadian Agency for Drugs and Technologies in Health: Ottawa (ON); 2014.
- Radwan A, Fess P, James D, et al. Effect of mattress designs on promoting sleep quality, pain reduction, and spinal alignment in adults with or without back pain: systematic reviews of controlled trials. Sleep Health. 2015;1(4):257-267.
- Collacott EA, Zimmerman JT, White DW, Rindone JP. Bipolar permanent magnets for the treatment of chronic low back pain: a pilot study. JAMA. 2000;283(10):1322-1325.
- Eccles NK. A critical review of randomized controlled trials of static magnets for pain relief. J Altern Complement Med. 2005;11(3):495-509.
- Moffett J, Fray LM, Kubat NJ. Activation of endogenous opioid gene expression in human keratinocytes and fibroblasts by pulsed radiofrequency energy fields. J Pain Res. 2012;5:347-357.
- Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2013;38(24):2124-2138.
- Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ. 2006;332(7543):696-700.
- Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
- NICE. Low back pain in adults: early management. CG88. London: National Institute for Health and Care Excellence; 2009.
- NICE. Low back pain and sciatica in over 16s: assessment and management. NG59. London: National Institute for Health and Care Excellence: 2016.
- Hsieh LL, Kuo CH, Yen MF, Chen TH. A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy. Prev Med. 2004;39(1):168-176.
- Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929.
- French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006;(1):CD004750.
- Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):492-504.
- Papuga MO, Cambron J. Foot orthotics for low back pain: the state of our understanding and recommendations for future research. Foot. 2016;26:53-57.
- MacRae S, Lewis J, Shortland A, Morrissey M, Critchley D. Rocker sole shoes are no more beneficial than flat sole shoes in the management of chronic low back pain. Physiotherapy. 2015;101(1):e922.
- Stout A. Interventions for low back pain: conclusions. Phys Med Rehabil Clin N Am. 2010;21(4):817.
- Heneghan C, Langton D, Thompson M. Ongoing problems with metal-on-metal hip implants. BMJ. 2012;344:e1349.
- WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New Millennium. The burden of musculoskeletal conditions at the start of the new millennium. World Health Organ Tech Rep Ser. 2003;919:i-x.
- Gray M. Value based healthcare. BMJ. 2017;356:j437.
- Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2016.