20 May 2024
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Managing low back pain; what has changed?

Dr Ross Walker
15 November 2022

Co-authored by Dr Stephanie Mathieson

Most people will experience low back pain in their life. For some of us, it feels like it is a daily occurrence, and there is a documented greater prevalence of low back pain with or without leg pain in persons 40 years and older.

Most cases of low back pain are considered to be non-specific, meaning there is no identifiable cause. Less frequent causes include back pain disorders with associated leg pain, like sciatica or herniated disc (5-10% of cases), or even rarer causes (less than 5%) due to serious pathology, such as vertebral fractures. Although uncommon, back pain may be a symptom of a more serious underlying disorder & if the condition does not settle with appropriate management, further investigations for systemic conditions need to be performed.

In general, episodes of low back pain have a favourable natural history with most cases resolving within 6 weeks. Unfortunately for some people, symptoms persist and become chronic (symptoms present for longer than 3 months).

What is new in the domain of low back pain research and clinical care?

There has been a shift from reliance on passive interventions, such as prescribing medicines, to more active management of the pain and individual, such as advice and exercise. A recent review found that individualized exercise therapy provided clinically important benefits at 3 months in patients with chronic low back pain3. While more modern applications of physical activity, e.g. virtual reality platforms, like activities using the Wii Fit Plus workout, found significant reduction in pain compared to using more traditional exercise in those with chronic low back pain.

Is there anything new? Well, there are new guidelines to manage people with low back pain in Australia. The Australian Commission released a new clinical care standard on Safety and Quality in Health Care (ACSQHC) which is part of the Australian Government  Department of Health and Aging, on the 1st of September 2022.

The Low Back Pain Clinical Care Standard5 describes the care you can expect if you go to a primary healthcare provider or a hospital emergency department with a new episode of low back pain

The standard contains eight quality statements. It describes things to expect in an initial clinical assessment and recommendations for patient management based on current evidence. Some recommendations include the following:

  • Doctors should provide patients with information about their condition to increase their understanding and manage realistic expectations.
  • Encourage self-activity and physical activity. If you have an episode of low back pain, you should return to your usual activities as soon as possible.
  • Doctors are to consider psychosocial factors that may influence the recovery of your back pain episode. This includes discussing any concerns you may have about your back pain and the impact pain may be having on your life, such as affecting your sleep.
  • To reserve imaging for suspected serious pathology. Almost all cases of back pain (95%) do not have any serious underlying cause. Therefore, imaging like x-rays should not be routine or conducted “just to see” if any changes in the spine are unnecessary and a waste of resources.

The standard includes two statements related to treatments.  One standard recommends that patients are offered physical and/or psychological interventions based on their clinical findings, and therapy is targeted at overcoming identified barriers to recovery. Examples of barriers could be not having the right strategies to manage pain.

Many patients benefit form mechanical therapies in the form of physiotherapy, osteopathy & a newer technique, Medkey, which is an electromagnetic device which delivers pulses into the affected area.

The other statement advises the judicious use of pain medicines and highlights that the role of analgesics is to enable physical activity and get you moving to return to normal activities, not to eliminate pain. The latter is a common misconception about pain medicines. This is important to acknowledge and help ensure people do not become reliant on them. Some medicines are advised to be avoided (e.g. opioid analgesics) because the risks are greater than the potential benefits, and some medicines are now not recommended at all for managing back pain (benzodiazepines (e.g. valium), antidepressants, and anticonvulsants (e.g. pregabalin) because their risk benefits ratio and recent evidence. For instance, pregabalin is no better than a placebo in reducing leg pain and back pain in patients with sciatica.

For general advice on managing back pain or if you have any questions, the Australian Commission on Safety and Quality in Health Care has made some resources available on their website to inform  people in the community.

Dr Stephanie Mathieson is a Research Fellow at the Institute for Musculoskeletal Health, University of Sydney.

References

1. Chiarotto A, Koes BW. Nonspecific low back pain. New England Journal of Medicine. 2022;386:1732-40.

2. Ropper AH, Zafonte RD. Sciatica. New England Journal of Medicine. 2015;372:1240-8.

3. Fleckenstein J, et al. Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability. Journal of Pain. 2022 Jul 29:S1526-5900(22)00364-9. doi: 10.1016/j.jpain.2022.07.005.

4. Brea-Gómez B, et al. Virtual reality in the treatment of adults with chronic low back pain: a systematic review and meta-analysis of randomized clinical trials. International Journal of Environmental Research and Public Health. 2021;18(22):11806.

5. Australian Commission on Safety and Quality in Health Care (ACSQHC) low back pain clinical care standard. https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standard

6. Mathieson S, et al. Trial of pregabalin for acute and chronic sciatica. New England Journal of Medicine. 2017;376:1111-20.

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