By Dave Emond
Back pain, what a riot, isn’t it? Whether you are someone who wants to learn more about your own health, or you are a health or fitness provider, you’ve probably dealt with one or more bouts of low back pain. This is because at any point in time, approximately 577 million people will be dealing with low back pain (1).
So most of us get back pain at some point, and luckily this tends to go away on its own within a few weeks, in the majority of cases (2). But this isn’t the case for everyone. Approximately 1 in 5 people will progress to chronicity when dealing with back pain - meaning pain for longer than 3 months, or repeated bouts over the course of time (3).
There are a number of factors that can play a role in the development of chronic or recurring bouts of pain. This may include our social environment and demographic (4), our beliefs and fear related coping strategies (5), and a variety of other factors. A recent paper showed the use of non-recommended therapies (based on best practice guidelines) can also increase the risk of developing chronicity when it comes to musculoskeletal pain (6). This is also dose-dependent, meaning the more non-recommended therapies offered, the higher the risk of developing chronicity (6).
Simple enough - don’t offer or seek non-recommended therapies. Well, from a patient perspective, this is easier said than done, as people tend to put their trust in the authority of their healthcare providers. What do we know about providers’ abilities to follow the guidelines? Well from Zadro’s paper in 2019, up to 43% of patients receive non-recommended therapies from their physiotherapists. These are not promising numbers.
Now, it’s important that I point out these last two points are separate. We still don’t have any studies associating the two. So we can only conclude that receiving poor primary care is not favourable for chronicity of pain, and that many practitioners aren’t following appropriate guidelines. We can’t, at this time, say that the poor use of guidelines by practitioners is causing chronic pain.
So to sum up the last few paragraphs, 1 in 5 people tend to progress to chronicity in a condition that typically resolves on its own, the risk of this happening increases when we use non-recommended therapies, and on a separate note, we know that a large portion of healthcare providers are not following best practice guidelines in the management of low back pain. This is where we are at with the management of low back pain.
Are we getting better?
In an award winning paper from 1987, Gordon Waddell writes that healthcare providers manage low back pain inappropriately, and suggests the best thing we can do to help reduce the global burden of low back pain is to step out of the way and reduce our overdiagnosis and overmanagement of the condition. This comes from a paper that is over 30 years old, yet we still march in the opposite direction.
We continue to see diagnoses handed out that lack any good quality supporting evidence, such as pelvic slips (9), core weakness (10), and postural syndromes for spinal pain (11). Clinicians continue to use non-recommended therapies, or therapies that have no recommendations in the management of low back pain including IFC, TENS, ultrasound, orthotics, acupuncture and traction in approximately 50% of cases (12).
Ok, enough of the doom and gloom. Let's turn this ship around with some positivity. It just so happens we have high quality recommendations for dealing with acute bouts of low back pain in an effective and appropriate manner. This is the information I hope to present coherently over the next few moments.
Recommendations for acute low back pain:
This is where we turn to the NICE guidelines for the assessment and management of low back pain with or without sciatica in those over 16 years of age. This is one of the higher quality guidelines we have available.
Assessment of acute low back pain
The first step of appropriate care is to rule out serious causes of low back pain, including cancer, infection, spondyloarthritis or traumatic injury. Once we have done this, we can move forward with more conservative means of care.
Next, using a tool like the STarT Back, a clinician can determine who is at a high risk of poor care outcomes. Those with lower risk tend to do well with minimal intervention, including reassurance and advice to stay active, and guidance on self-management strategies. Those with higher risk may benefit from an exercise program to promote movement and activity, with or without manual therapy, or psychological interventions such as cognitive behavioural therapy.
The guidelines also recommend avoiding routine imaging in a non-specialist setting for those presenting with low back pain. Although it is of popular belief that imaging will always reveal the cause of pain, this is often not the case (14).
Management of acute low back pain
So what do the guidelines recommend for the management of low back pain?
Advice on self-management: Clinicians should be offering strategies to patients on how to help manage their pain on their own, and educating on the importance of continued movement and activity as best as possible. People should also be informed that most cases of low back pain resolve after a few weeks.
Exercise: Group or individualized exercise programs may be a strategy to promote continued movement. Exercises don’t need to be specific, so someone’s preferences, needs and abilities must be taken into consideration.
Manual therapy: This can be considered, but only when combined with exercise. It shouldn’t be offered a standalone treatment. These adjunct therapies can include spinal manipulation, mobilizations or massage.
Psychological therapy: Some psychological therapies may be considered if using a cognitive behavioural approach.
A focus on returning to work as soon as tolerable should also be prioritized if someone is missing work due to their low back pain.
There are also pharmacological recommendations as part of the guidelines, however, this falls out of my personal scope. I won’t chat about these, but feel free to consult a physician.
The NICE guidelines also have a list of therapies that we should not be offering for the management of low back pain. I’ll leave it in a list format.
Electrotherapies (IFC, TENS, Ultrasound, percutaneous electrical nerve stimulation)
Belts or corsets
I'll make note here, these are all therapies that are frequently offered to people seeking care, as documented in the Murtagh study.
The best practice guidelines offer our most effective strategies for managing low back pain for the majority of people. There may be some outliers in either direction, however this does not mean should ignore best practice, or turn to non-recommended therapies as a first line treatment.
So there you have it. Most acute cases of low back pain, although unpleasant or worrisome, tend to self-resolve with time. For some in need of a little guidance or relief, we have good recommendations set in place in how to appropriately manage back pain, and hopefully avoid a transition to chronicity.
Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain. 2020 Sep;161(1):S57.
Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. The Lancet. 2014 Nov 1;384(9954):1586-96.
Goldberg DS, McGee SJ. Pain as a global public health priority. BMC public health. 2011 Dec;11(1):1-5.
Picavet HS, Vlaeyen JW, Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. American journal of epidemiology. 2002 Dec 1;156(11):1028-34.
Stevans JM, Delitto A, Khoja SS, Patterson CG, Smith CN, Schneider MJ, Freburger JK, Greco CM, Freel JA, Sowa GA, Wasan AD. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA network open. 2021 Feb 1;4(2):e2037371-.
Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ open. 2019 Oct 1;9(10):e032329
Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine. 1987 Sep 1;12(7):632-44.
Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M, Moloney N, Vaegter HB, Bagg MK, Travers M. Changing the narrative in diagnosis and management of pain in the sacroiliac joint area. Physical therapy. 2019 Nov 25;99(11):1511-9.
Lederman E. The myth of core stability. Journal of bodywork and movement therapies. 2010 Jan 1;14(1):84-98.
Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents.
Murtagh S, Bryant E, Hebron C, Ridehalgh C, Horler C, Trosh C, Olivier G. Management of low back pain: Treatment provision within private practice in the UK in the context of clinical guidelines. Musculoskeletal Care. 2021 Feb 28.
de Campos TF. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59]. J Physiother. 2017 Apr 1;63(2):120.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015 Apr 1;36(4):811-6.