Prevention and treatment of low back pain: evidence, challenges, and promising directions

Abstract

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Advancing cell therapies for intervertebral disc regeneration from the lab to the clinic: Recommendations of the ORS spine section

“…Conventional treatments for disc degeneration are focused solely on alleviation of symptoms and often have limited long‐term efficacy . This is exacerbated by the lack of an accepted clinical standard for discogenic pain, where clinicians are often unable to identify a specific nociceptive cause . Because of this, the rationale for choosing surgery for these patients is controversial.…”

Early development of the Australia and New Zealand Musculoskeletal Clinical Trials Network

“…Similar to the Australian-initiated trials registered during this time, approximately half were for osteoarthritis (n = 14), and approximately half were investigating physical therapies (n = 14). Similar to the Australian-initiated trials registered during this time, approximately half were for osteoarthritis (n = 14), and approximately half were investigating physical therapies (n = 14).…”

“…9 Similarly, in New Zealand the Health Research Council invested 7% of its budget in musculoskeletal conditions compared with 14% for vascular disorders and 12% for cancer in the 2013/2014 year. 11 Examples of vast delays in translating musculoskeletal research into clinical practice include continued use of ineffective arthroscopic debridement for knee osteoarthritis, 12,13 continued over-diagnosis and overtreatment of non-specific low back pain, 14 suboptimal treatment of gout, 15 under-utilisation of nonpharmacological and lifestyle management strategies for osteoarthritis 16 and under-treatment to prevent refracture following minimal trauma fracture. In 2014, 16% of 159 arthritis-relevant NHMRC applications were successful compared with 18% of 730 cardiovascular, 19% of 409 diabetes and 16% of 504 mental health applications.…”

Evidence-based physiotherapy needs evidence-based marketing

“…Early access to harmful or ineffective physical therapy treatments (eg, kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes7 or solve the opioid crisis. Treatment content should be marketed accurately as it is supported by thousands of trials and systematic reviews and is central to evidence-based physical therapy.…”