Low back pain, the gaps between evidence and practice.

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

Recommendations include use of a bio-psychosocial 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. But, are we applying the guidelines!!

Prevention

• Moderate quality evidence existed that Exercise alone, or in combination with education, is effective for prevention.

• Poor to very-poor quality evidence existed that education alone, back belts, shoe insoles, and ergonomic programmes might not be effective.

• Very low quality evidence existed that ergonomically designed furniture could prevent low back pain compared with conventional furniture.

Treatment

• Early management are that individuals should be provided with advice and education about the nature of low back pain and radicular pain.

• Reassurance that they do not have a serious disease and that symptoms and encouragement to avoid bed rest, stay active, and continue with usual activities, including work.

• For patients who have not responded to first line treatments, and who are substantially functionally disabled by pain, multidisciplinary rehabilitation programmes with coordinated delivery of supervised exercise therapy, cognitive behavioural therapy, and medication are more effective than standard treatments.

• Guidelines encourage active treatments in form of early graded and supervised exercise therapy. No form of exercise is better than another.

• Greater emphasis is now placed on self management physical and psychological therapies, and some forms of complementary medicine with less emphasis on pharmacological and surgical treatments.

• Passive therapies, such as spinal manipulation or mobilisation, massage, and acupuncture, are considered as optional, and suggested as a short course for patients who do not respond to other treatment.

• Other passive electrical or physical modalities, such as ultrasound, transcutaneous electrical nerve stimulation,traction, interferential therapy, short-wave diathermy and back supports are generally ineffective and not recommended.

• Pharmacological treatment only recommended following an inadequate response to first-line nonpharmacological interventions. Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction potential, and poorer long-term outcomes.

• Recent guidelines do not recommend spinal epidural injections or facet joint injections for low back pain but do recommend consideration of epidural injections (small short-term <4 weeks) of local anaesthetic and steroid for severe radicular pain.

• Surgical treatment, patients tend to improve with or without surgery, benefits diminish with longer (>1 year) follow-up and, therefore, non-surgical management is an appropriate option for patients who wish to defer or avoid surgery.

The global gap between evidence and practice

• Overuse of low-value care and underuse of high-value care.

• Access to best practice can be constrained by availability and patients’ uncertainty (A real challenge).

• In all countries, access to structured exercise programmes is variable, and poor access to cognitive behavioural therapy and multidisciplinary rehabilitation programmes.

Effective and promising solutions

• Documentation and using Screening Tool, A new model is the STarT Back (https://www.keele.ac.uk/sbst/startbacktool/).

• Reconfiguration of the whole clinical pathway.

• Public health interventions, aim to change the public’s back pain beliefs and behaviours

- Media campaigns.

- Training for individuals in back pain prevention and management and Promote a healthy lifestyle.

- Address widespread misconceptions in the population and among health professionals about the causes, prognosis, and effectiveness of different treatments for low back pain, and deal fragmented and outdated models of care.

- National and international funding for the low back pain research.

- Change clinician behaviour, provide targeted evidence based training of health-care professionals.

Key messages

• Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine.

• Less emphasis on pharmacological and surgical treatments; routine use of imaging and investigations is not recommended.

• Effective interventions for secondary prevention being exercise combined with education, and exercise alone.

• Non-evidence-based practice is apparent across all income settings; common problems are presentations to emergency departments and liberal use of imaging, opioids, spinal injections, and surgery.

• Guidelines also recommend that laboratory tests and imaging should not be routinely used as part of early management.

• The implementation of evidence-based interventions by a physical therapist earlier in the course of care prove more cost-effective by promoting recovery and reducing the need for more invasive and costly interventions.

• Adherence to guideline-based recommendations for LBP has been associated with improved clinical outcomes.

Guidelines

- Implementation of low back pain guidelines in general practice- Danemark

https://fysio.dk/globalassets/documents/fafo/afhandlinger/phd/2016/allan_riis_phd-thesis_2016.pdf

- European guidelines for the management of acute nonspecific low back pain in primary care

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3454540/pdf/586_2006_Article_1071.pdf

- Low back pain: the acute management of patients with chronic (longer than 6 weeks) non-specific low back pain- NICE guidlines

https://www.nice.org.uk/guidance/cg88/documents/low-back-pain-draft-full-guideline2

References

• Childs, J.D., Flynn, T.W. and Wainner, R.S., 2012. Low back pain: do the right thing and do it now.

• Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., Ferreira, P.H., Fritz, J.M., Koes, B.W., Peul, W. and Turner, J.A., 2018. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet.

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