A group of 30 international authors recently published a Back Pain Series in the Lancet journal. It covers the most recent research into back pain in terms of effective and ineffective interventions and treatment and how we understand pain. Below is an overview of the current recommendations for low back pain, based on the most recent research and evidence.
Low back pain is very common. So common in fact, it is now the leading cause of disability world-wide. In 2015, low back pain was responsible for more than 60 million years lost to disability world-wide1. This global economic and societal burden is projected to further increase in the coming years as the result of an aging population, urbanisation and the use of technologies that relate to increasingly sedentary lifestyles1,2.
For those of us who have experienced initially strong and disabling back pain, it may be tempting to seek an X-ray, CT scan or MRI, in an attempt to diagnose the cause of the pain. However, except in rare cases, such as a spinal fracture or tumour, it is often not possible to identify a specific cause of low back pain3. Furthermore, scans for lower back pain in which fracture or tumour is not considered likely, can actually confuse the issue. An MRI can show findings that may be incorrectly attributed to the cause of a patient’s pain. Two people can have exactly the same findings, for example a disc bulge, but one will feel no pain at all3. It is important for people to be assured that most episodes of low back pain will be short and with little or no consequence4.
What about pharmaceutical pain relief for low back pain? What works?
The Lancet Back Pain Series found the use of paracetamol to have little effect on acute low back pain and together with its potential for harm, has led to recommendations against its use5. Associate Professor Mark Hancock was one of the authors who worked on the Series and says a short period on anti-inflammatories may be helpful in helping to get the person moving, but to try to avoid the use of opioids in almost all cases.
Back pain is the main reason people use opioids over a long period of time and substantial risks exist due to their potential for addiction, overdose and poorer long-term outcomes6.
Do I need surgery?
Desperate for pain relief, patients may look to surgery, but again, according to the latest research, surgery is rarely the best option for back pain2,8. And yet lumbar spine surgery rates are roughly doubling every 10 years.
There are exceptions where spinal surgery may be warranted, for example in cases of trauma, tumour or neurological deficit from instability or displacement of the vertebrae. But for patients with typical degenerative changes in the spine and chronic low back pain, without a significant neurological problem, spinal surgery is not indicated or advisable. Surgery is expensive and increases the risk of harm and there is no high-level evidence of a benefit in these cases2.
What about cortisone injections? Do they work?
Many people have sought, or been advised to have, a cortisone injection to treat low back pain. However, the Lancet researchers also found little evidence to support the effectiveness for these injections7.
Associate Professor Mark Hancock who worked on the Series, says that “The best estimate we have from previous studies is that corticosteroid injections reduce sciatica (leg pain associated with back pain) by only five points on a 100-point scale compared to placebo in the short term, with no long term benefit.”
So where does that leave us? Well the research helps us there too…
We can start by reframing the way we think about pain. The latest research indicates that the brain creates pain as a protective mechanism, not a measure of tissue damage4. High intensity of pain and accompanying distress often causes people to stop moving and lay down and ‘rest’ but this can lead to stiffness and weakness and often causes more harm.
Associate Professor Mark Hancock says it is important for patients to understand it is safe to move, even into a little bit of pain and that they will start to get better. Exercise can not only provide pain relief, but also help in the prevention of further episodes by 50 per cent. There is no strong evidence that one type of exercise is superior to another, most exercise is beneficial2.
So talk to us. As physiotherapists we are perfectly positioned with the expertise and skills to assess your back and get you moving again, with confidence and without fear. We can help you find the most appropriate exercise, which may be as simple as going for a walk or a swim. It could be a dance class or a Pilates class. The option are as wide and varied as you care to consider!
GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017; 390: 1211–1259
Foster, NE, Anema, JR, Cherkin, D et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. (published online March 21.)Lancet. 2018
Jame, SZ, Sari, AA, Majdzadeh, R, Rashidian, A, Arab, M, and Rahmani, H. The extent of inappropriate use of magnetic resonance imaging in low back pain and its contributory factors. Int J Prev Med. 2014; 5: 1029–1036
Hartvigsen, J, Hancock, MJ, Kongsted, A et al. What low back pain is and why we need to pay attention. (published online March 21.)Lancet. 2018
Machado, GC, Maher, CG, Ferreira, PH et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015; 350: h1225
Dowell, D, Haegerich, TM, and Chou, R. CDC guideline for prescribing opioids for chronic pain: United States, 2016. JAMA. 2016; 315: 1624–1645
Chou, R, Hashimoto, R, Friedly, J et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med. 2015; 163: 373–381
Chou, R, Baisden, J, Carragee, EJ, Resnick, DK, Shaffer, WO, and Loeser, JD. Surgery for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009; 34: 1094–1109