Low back pain: a comprehensive review of The Lancet Low Back Pain Series

Lancet low back pain series is a series of three papers published in the Lancet Journal in 2018. The most important message highlighted by these papers, according to the Lancet, is quoted here:

A major challenge will be to stop the use of harmful practices while ensuring access to effective and affordable healthcare for people with low back pain. (THE LANCET)

Here we will discuss each paper in sequence as published in the Lancet journal, starting with the first paper (1) and then proceeding to the second (2) and third paper (3).

In this blog, we will discuss paper number 2: Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions.

PREVENTION AND TREATMENT OF LOW BACK PAIN: EVIDENCE, CHALLENGES, AND PROMISING DIRECTIONS (2)

TRADITIONAL MANAGEMENT OF LOW BACK PAIN

If we see the management of low back pain from a traditional perspective, we will see a very biomedical or structural approach to the diagnosis of low back pain. According to this approach, we usually examine the patient, do some imaging in order to identify the structures responsible for the patient’s pain, and match the particular treatment to the structure causing low back pain. According to this paradigm, diagnostic systems are usually involved, matching specific treatments to particular clinical findings, and if we deliver that treatment, the patient should be cured.
Problem with the traditional paradigm
The problem with this traditional approach is that we rarely are able to identify the structure responsible for a patient’s pain. In some cases, where we may be able to identify the nociceptive structure, we might not have a treatment that matches all these clinical findings.
The Patient usually expects to be cured and becomes very frustrated when they have persistent pain or pain that recurs after a period of time. If the patient has a recurrence, they start looking in the past for another explanation because they think the clinician may have gotten the examination wrong and did not make the correct diagnosis. This paradigm of chasing a biomedical diagnosis might be responsible for much of the disability we see today.

IMAGING AND BACK PAIN

The findings that we see on MRI or X-ray, including disc degeneration, disc bulge, spondylosis, and spondylolisthesis, there is no doubt that these findings are common in people with low back pain but are also very prevalent in people who do not have low back pain, regardless of how old they are.
We know there exists a positive association between degenerative changes in the spine and low back pain, but many people with multiple findings on imaging may have none or very little pain.

Prevalence of findings on imaging for different age groups
The prevalence of different findings on imaging increases with age, and when people are 80 years or old, the prevalence of these finding reach about 100%. It means that people who are 80 years or old may have these findings but don’t have low back pain (9, 10).
If we look at the evidence regarding whether or not MRI findings can identify patients with low back pain or sciatica who respond to a particular intervention, there is resounding evidence that the answer is no. Even if we look at whether or not imaging has a role in identifying people at risk for developing future low back pain, the answer is still no. Still, we don’t have any evidence supporting imaging to screen people for low back pain, even though it has been used in some settings (9, 10). 

The evidence is insufficient to know whether MRI findings can predict the future onset or the course of low back pain. Importantly no evidence exists that imaging improves patient outcomes.
Guidelines consistently recommend against the routine use of imaging for people with low back pain. Many radiological guidelines tell us when to use the imaging, but in most patients with low back pain, it is not indicated.

RED FLAGS IN LOW BACK PAIN DIAGNOSIS

The recent literature on red flags in low back pain consistently says that nearly all individual red flags are uninformative and do not change the post-test probability of a serious abnormality. In other words, if a patient presents with a red flag in a clinic, the chances that the person will have a malignancy or other serious condition are rare. The very low specificity of these individual red flags contributes to unnecessary specialist referral and imaging (11).

Empirical support for many of these individual red flags is rare for malignancy. Referring every patient with a red flag to imaging, a medical specialist, or other invasive testing is not the answer. We need more research on how a clinician in primary care should behave to find the rare cases of serious pathology in low back patients.

PREVENTION OF LOW BACK PAIN

A systematic review of four studies on the prevention of low back pain concluded that the most significant intervention to prevent the occurrence and recurrence of low back pain is the combination of exercise and education. It can reduce the recurrent episodes of low back pain by 45%. Such a significant effect of this combination of interventions can be used as a successful preventive tool to reduce recurrent episodes of low back pain (12).

 Figure reproduced from Steffens, et al, JAMA Intern Med., 2016

TREATMENT FOR LOW BACK PAIN

Education and self-care
Education, self-care, and advice to remain active are universally recommended for both acute and persistent back pain.
 Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

Non-pharmacological therapy
For acute low back pain (<6 weeks), non-pharmacological therapy may include spinal manipulation, massage, acupuncture, and cognitive-behavioral therapy. Most guidelines do not recommend exercise therapy during the acute phase at all.
For persistent low back pain (>12 weeks), exercise and cognitive functional therapy-based treatments are recommended universally with other non-pharmacological therapies.
 Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

Pharmacological therapy
Today most guidelines do not recommend pharmacological therapy as first-line therapy. The pharmacological therapy may range from paracetamol and NSAIDs to muscle relaxants and other pharmacological treatments.
Recent guidelines from the American College of Physicians recommend that in both acute and chronic low back pain, both clinicians and patients should consider non-pharmacological treatment and try it before using pharmacological treatment (13).

 Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

Invasive treatment
There is little or no evidence for invasive treatment in the case of acute low back pain. Surgery may be helpful in case of a herniated disc and spinal stenosis.
Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

HOW SHOULD WE MANAGE A PATIENT WITH PERSISTENT LOW BACK PAIN?

We should manage patients with low back pain using a holistic approach, including addressing the nociceptive structures in the back, pain processing, psychological components, and co-morbidities.

Addressing pain processing and pain perception
We can address pain processing and pain perception in the brain by talking to patients about these mechanisms by talking to them about:

• Pain education
• Sleep education
• Exercise
• Mindfulness
• Cognitive behavioral therapy (CBT) informed treatment

Addressing psychological distress

• Address and confront pain-related fear
• Improve self-efficacy through challenges and exercise
• Engage in work disability prevention
• Cognitive behavioral therapy (CBT) informed treatment

Addressing biological component
To address the biological component of a patient’s pain, we as clinicians can utilize several interventions, including:

• Various exercises
• Manual therapy
• Physical activity
• Surgery

Addressing the patients with co-morbidities
To address the co-morbidities in the patients presenting with low back pain, we would probably co-manage the patient with other healthcare providers.
The things we prescribe, like keeping active, exercise, physical activity, cognitive behavioral therapy (CBT) informed treatment, and lifestyle advice, can be tremendously helpful for both back pain and whole health and life.
 

REFERENCES:

1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-67.
2. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368-83.
3. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-8.
4. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-37.
5. MacNeela P, Doyle C, O'Gorman D, Ruane N, McGuire BE. Experiences of chronic low back pain: a meta-ethnography of qualitative research. Health Psychol Rev. 2015;9(1):63-82.
6. Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013;17(1):5-15.
7. Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskeletal Disorders. 2016;17(1):220.
8. Chen Y, Campbell P, Strauss VY, Foster NE, Jordan KP, Dunn KM. Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain. 2018;159(2):252-60.
9. Steffens D, Hancock MJ, Maher CG, Williams C, Jensen TS, Latimer J. Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain. 2014;18(6):755-65.
10. Steffens D, Hancock MJ, Pereira LS, Kent PM, Latimer J, Maher CG. Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review. Eur Spine J. 2016;25(4):1170-87.
11. Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.
12. Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199-208.
13. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Denberg TD, Barry MJ, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-30.