Are you hot or cold on pain management?

ACOEM provides evidence-based guide

When employees complain of back pain, they often receive the conventional wisdom about how to get relief and hasten their recovery. Rest. Ice the area. Take some pain meds. Unfortunately, that conventional wisdom may be wrong.

The American College of Occupational and Environmental Medicine (ACOEM) has issued updated guidelines for chronic pain management to promote the use of evidence-based treatments for this very common ailment. The guidelines clearly state which treatments have been shown to be effective — and which are unproven or even potentially harmful.

"We want the injured workers in the United States to receive the most efficacious treatment for work-related injuries at the earliest possible date," says Kurt Hegmann, MD, MPH, associate professor and director of the Rocky Mountain Center for Occupational and Environmental Health at the University of Utah in Salt Lake City, who is editor-in-chief of the guidelines. "The guidelines have detailed advice on what does and doesn't work."

These guidelines are especially important because of the magnitude of the problem. About 46% of workers report having had low back pain in the past two months, according to Hegmann, who has conducted epidemiologic studies. That figure is even higher for health care workers, who face patient-handling hazards and are older than the general work force, he says.

Even health care providers often are mistaken about the best way to manage back pain, he says. "There are specific efficacious strategies and a lot of people don't know them, and there are also a lot of false beliefs about what is efficacious."

What works? Nonsteroidal anti-inflammatory medication. Muscle relaxants may be helpful, especially at night. A gradually progressive aerobic exercise program, such as walking. Heat applied to the area. Directional or slump stretch, or stretching in the direction that eases the pain.

Manipulation, as performed by chiropractors and others, has proven beneficial for some low back pain patients. "We don't recommend [ongoing] multiple treatments. If something doesn't get better in the first four, five, or six treatments, it should be stopped," Hegmann says.

Misconceptions about relief of back pain seem as commonplace as the condition itself. Many of the treatments are based on longtime assumptions rather than carefully controlled studies, he says.

"We've reviewed over 500 trials on low back pain alone. Every single placebo treatment arm gets better. The natural course is to improve," says Hegmann. "In order to be efficacious, treatment has to improve [the condition] at a rate better than placebo."

Each person needs to be assessed, and their treatment should be based on the best available information about efficacy, he says. The ACOEM guidelines provide more than 500 pages of recommendations, defining the level of evidence for each.

Here are some common but false beliefs about low back pain:

  • Early treatment of low back pain will prevent the condition from worsening. Although this seems like common sense advice, there are no data to support it. While restrictions on heavy lifts or other job tasks that aggravate the problem, such as prolonged sitting, may be appropriate, employees do not necessarily need to be removed from their job, says Hegmann.
  • Bed rest will provide relief and hasten healing. All quality studies fail to demonstrate any benefit from bed rest for acute low back pain, and in fact it can cause deconditioning and elevate the risk of blood clots, he says. It also is not recommended for subacute and chronic low back pain.
  • Opioids such as oxycodone are important tools to improve function through reduced pain. Opioids should be reserved for patients with the most severe condition or for use before bedtime to reduce pain at night. Otherwise, anti-inflammatories have been shown to be as effective without the potential significant side effects. "It's recommended that they're not for routine use and they're reserved for more severely affected individuals," says Hegmann. "We also recommend that they are not generally prescribed for chronic pain patients unless there is evidence of functional improvement while using them and other treatment strategies have failed."

(Editor's note: Information about the chronic pain guidelines, which are a part of broader occupational medicine practice guidelines, is available from the American College of Occupational and Environmental Medicine at