A series of two articles and a viewpoint piece published in the Lancet by teams of international experts outlined the array of factors that contribute to low back pain (LBP),1 presented prophylactic strategies and treatment options for the condition,2 and issued a call for international and national organizations to take action to alleviate the LBP-associated global burden.3 In an accompanying comment, Lancet editors pointed to the increasing worldwide prevalence of LBP, particularly in low- and middle-income countries, as indicated in a global study that examined the incidence and prevalence of a number of diseases between 1990 and 2016 at the national and the global level.4
In the first article, investigators from the department of sports science and clinical biomechanics at the University of Southern Denmark in Odense and at the Nordic Institute of Chiropractic and Clinical Biomechanics, also in Odense, pointed to the high worldwide prevalence of LBP, estimated at 7.3% in 2015.1,4 They also emphasized the increasing burden resulting from LBP-associated disability in low- and middle-income countries in the past few decades, “where health and social systems are poorly equipped to deal with this growing burden in addition to other priorities such as infectious diseases.”1,5
“Rarely can a specific cause of low back pain be identified; thus, most low back pain is termed non-specific,” wrote the authors, noting that the approach to LBP varies from one country to another based on a combination of social factors, legislation, and approaches to healthcare. “In low-income and middle-income countries, formal and informal social-support systems are negatively affected, while in high-income countries, the concern is that the prevalent healthcare approaches for low back pain contribute to the overall burden and cost rather than reducing it,” they note, highlighting the fact that approaches to healthcare need to be undertaken at a global level.
For the first article, the investigators searched medical databases to identify studies that examined the causes of LBP in low- and middle-income countries.1 “Low back pain is a symptom, not a disease, and can result from several different known or unknown abnormalities or diseases,” they stated. Identified contributors to LBP and LBP-related disability are genetic, biophysical, social, and psychological factors, as well as comoborbidities. These factors are known to interact, resulting in the “pain experience,” a combination of nociceptive input (of nonidentified or neurological origin or resulting from a specific pathology) and central pain processing (eg, sensitization).
A set of abnormalities identifiable on magnetic resonance imaging (MRI) have shown moderate associations with LBP, according to a systematic review of MRI findings from 3097 individuals.6 These include Modic type I change, disc bulge, disc extrusion, and spondylolysis. However, available evidence does not allow prediction of the onset or course of LBP and using MRI for that purpose in patients with LBP is not advised. Radicular pain (eg, from disc herniation), radiculopathy, and lumbar spine stenosis have all been identified as neurological causes of LBP, the first two of which result in poorer outcomes. Other causes include inflammatory disorders (eg, spondyloarthritis), vertebral fractures, malignancy (eg, adenocarcinomas metastasizing to the spine), and infections (spinal, eg, spondylodiscitis; or bacterial, eg, tuberculosis).
Despite the fact that the majority of individuals with LBP experience low-level disability, several disabilities may accumulate in this population. This, in addition to the high levels of disability experienced by a minority of individuals, results in a societal burden associated with the condition estimated in 2015 at 60.1 million years lived with disability. LBP-associated disability is known to affect work, which “might contribute to the cycle of poverty in poorer regions of the world,” have an impact on social identity, result in inequality, and be associated with high direct and indirect costs in high-income countries.
Factors Contributing to Persistent, Disabling LBP
- Biophysical: structural changes in and impaired stabilization of lumbar muscles
- Psychological: anxiety, depression, pain catastrophizing, and fear avoidance
- Social: low income, education levels, and work satisfaction
- Lifestyle: high body mass index, smoking, low levels of physical activity
- Symptom-related: leg pain, previous episodes of LBP, high intensity of LBP
“Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden,” concluded the article authors.
Preventing and Treating LBP: Effective Approaches
The second article of the series, authored by an international group of researchers, reviewed studies investigating prevention and treatment strategies for LBP.2 “[Existing] 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,” noted the authors.
Effective strategies for the prevention of LBP identified through a literature search include exercise, either alone or in combination with education (moderate quality evidence for both). Based on very low- to moderate-quality evidence, back belts, shoe insoles, education alone, or ergonomic interventions in the workplace were all found to be ineffective for preventing LBP.
Evidence-based guidelines recommend LBP education and self-care (ie, active lifestyle and superficial heat treatment) for the first-line and routine treatment of nonspecific acute (<6 weeks) and persistent (>12 weeks) LBP. Several nonpharmacologic therapies are also recommended as first-line and routine treatment options for persistent LBP, including exercise and cognitive behavioral therapies. Alternatives such as spinal manipulative therapy, massage, and acupuncture, are advanced as second-line or adjunct treatment options in both acute and persistent LBP, while yoga, mindfulness-based stress reduction, and interdisciplinary rehabilitation are recommended as second-line/adjunct options in persistent LBP.
Pharmacologic options include nonsteroidal anti-inflammatory drugs (second-line or adjunct therapy in acute and persistent LBP), selective norepinephrine reuptake inhibitors (second-line or adjunct therapy in persistent LBP), while skeletal muscle relaxants and opioid medications should be restricted to a subset of patients and used cautiously. Paracetamol and systemic glucocorticoid use is recommended against, and insufficient evidence supports the benefit of anti-seizure medications in LBP.
Epidural glucocorticoid injections for herniated disc with radiculopathy are not recommended in acute LBP and should only be used in select patients. Surgical interventions including discectomy for herniated disc with radiculopathy and laminectomy for symptomatic spinal stenosis should only be used as second-line or adjunct treatment options in persistent LBP.
The researchers emphasized the presence of a “global gap between evidence and practice,” adding, “Tremendous opportunity exists to improve healthcare outcomes and potentially reduce costs by effectively implementing known best practice recommendations.” Identified gaps include management of LBP in the primary care setting (guideline) vs in the emergency department or by a specialist (practice), education and advice as part of LBP management (guideline) vs absence of it (practice), physical activity and continued work (guideline) vs rest and absence from work (practice), and non-pharmacologic therapy as first-line (guideline) vs pharmacotherapy as the first option (practice).
“Implementation strategies need to be tailored to overcome specific barriers to change and feature education and training, social interaction, clinical decision support systems, and targeted reminders,” noted the authors, who pointed to short consultation times and fear of litigation as two of the hurdles to the implementation of best practices. They recommended integration of healthcare and occupational interventions, as well as the use of public health interventions (eg, mass media campaigns on back pain) to bridge this gap, and concluded that “Focusing on key principles, such as the need to reduce unnecessary healthcare for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps.”
In the final part of this Lancet series on LBP, a viewpoint article titled “Low back pain: a call for action,” by an international group of researchers outlined the multiple challenges to the prevention of LBP at a global level.3 They recognized political challenges associated with the insufficient recognition of the back pain-related burden and called on policymakers at the international (ie, World Health Organization [WHO]) and national levels to make LBP a global health priority and fund public health approaches to the prevention of LBP, respectively. The persistence of LBP-associated disability represents a public health challenge that requires prioritization of the condition and a modification of systems and practices. The need to take a distance from a fragmented and biomedical approach to LBP prevention constitutes an important healthcare challenge.
“Improved recognition of the growing burden of low back pain is essential to stimulate new, more effective strategies of prevention and care,” concluded the authors, adding “Strong and coordinated political action from international and national policy makers, including WHO and research funding agencies, is needed. Such action could substantially reduce disability and suffering and improve the effectiveness and efficiency of care for people with low back pain throughout the world.”
- Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention [published online March 21, 2018]. Lancet. http://dx.doi.org/10.1016/S0140-6736(18)30480-X
- Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions [published online March 21, 2018]. Lancet. http://dx.doi.org/10.1016/S0140- 6736(18)30489-6
- Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action [published online March 21, 2018]. Lancet. http://dx.doi.org/10.1016/ S0140-6736(18)30488-4
- GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-1259.
- Hoy DG, Smith E, Cross M, et al. Reflecting on the global burden of musculoskeletal conditions: lessons learnt from the global burden of disease 2010 study and the next steps forward. Ann Rheum Dis 2015;74:4-7.
- Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta-analysis. Am J Neuroradio 2015;36:2394-2399.