Low back pain: New evidence to help you avoid the same old treatment

By: Jason Gallant, Registered Physiotherapist

Low back pain has become the leading cause of disability worldwide, and its prevalence continues to increase in our aging population. 80% of Canadians will experience low back pain in their lifetime, and this can often be a painful and frustrating recovery process. A recent series of studies published in March in the prominent medical journal “The Lancet” focuses on the epidemic of low back pain across the world, its widespread effect on our population, and how it can most effectively be treated. Here’s what the researchers found:

While most episodes of low back pain are short lasting, it is common for it to reoccur and can last for variable amounts of time. It is a very complex condition with many contributors that are not strictly physical. These include psychological, social, and lifestyle factors, as well as our individual pain processing mechanisms. All these factors need to be considered when treating low back pain.

What was concerning about the study is the treatment that people suffering with low back pain are receiving. There are many similar evidence-based guidelines in the literature that outline how to manage low back pain, but unfortunately there is still a large gap between evidence and practice. Here is what we know:

Diagnostic imaging (X-ray, MRI) should only be prescribed if the clinician thinks that it is something other than non-specific low back pain. However, the study showed that the majority of patients are prescribed X-rays, regardless if their symptoms warrant one or not.

The first treatment of choice should be non-pharmacological, and should involve education and advice. The study found that many patients are simply prescribed medication on their first visit to the doctor, and not given any education about what is causing their pain or what they should do about it. Many patients are even prescribed opioid (a type of narcotic) medications. The evidence discourages these as their effectiveness has not clearly been proven and there is a risk of addiction.

The study showed that when patients do get education or advice, it is often the wrong kind. Many health care practitioners are still prescribing bedrest, and recommending that the patient not return to work until they are almost pain free. The evidence clearly shows better patient outcomes when people stay active and have a return to work.

When seeing a physiotherapist, many patients with low back pain are still being treated with modalities such as electrical stimulation or traction. These are not recommended in the low back pain guidelines, as they have not been proven to be effective. Exercise has shown to be highly effective in treating low back pain, but some therapists are still not prescribing it, and opting for passive treatments instead.

Interventional procedures such as injections and surgical procedures have been shown to have a limited role in the management of low back pain, but again, they are still widely happening. In 2011 in the US, spinal fusion surgeries accounted for the highest hospital costs of any procedure, and injection procedures to the low back were performed over 1 million times!

Lastly, the guidelines clearly show the importance of managing the psychological role in the production of low back pain, meaning pain is not only caused by physical factors. Things like anxiety, depression, and workplace stressors all play a role in the production of pain and need to be addressed. But only 12% of Americans with low back pain AND depression had seen a psychologist or psychiatrist in the past year, and only 8% were prescribed cognitive behavioral therapy.

This study should be very concerning for the healthcare community to know that many practitioners across the world are failing to meet their patient’s needs when it comes to low back pain. The medical community as a whole needs to give up old habits and beliefs and embrace the large body of evidence that they are responsible to be familiar with. We cannot simply “do no harm”, we need to do what has been proven to be best for our patients.

It is even more concerning to you as a patient to know you may not be getting the proper care you need to help treat your low back pain. You have a right to receive the most effective treatment possible, instead of what may be easiest or feel the best at the time. So you need to ask yourself a few questions the next time you are seeking help:

• Is my doctor prescribing me medications and bedrest, or encouraging me to stay active and exercise?
• Am I being referred for diagnostic testing or neurosurgery, or referred to a physiotherapist or psychologist if needed?
• Is my physiotherapist/chiropractor/osteopath putting me on a machine and giving me a massage, or are they giving me a home exercise program and encouraging me to move as much as possible?
• Are they treating only my physical symptoms, or delving into other various factors that could be causing my pain?
• Are they giving me a 2 word diagnosis, or taking the time to explain what is causing my pain, and what I can do to help it?
• My hope is that everyone suffering from low back pain can find someone to give them the right answers to these questions.

Source: Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, published March 21, 2018.