Elsevier

The Lancet

Volume 391, Issue 10137, 9–15 June 2018, Pages 2368-2383
The Lancet

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

https://doi.org/10.1016/S0140-6736(18)30489-6Get rights and content

Summary

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.

Introduction

Despite the plethora of treatments and health-care resources devoted to low back pain, back-related disability and population burden have increased.1, 2 The first paper3 in this Series describes the global burden and effect of low back pain and provides an overview of the causes and course of low back pain. In this Series paper, we summarise the evidence for effectiveness of interventions for the prevention and treatment of low back pain and the recommendations from best practice guidelines. Despite generally consistent guideline recommendations around the world, clear evidence exists of substantial gaps between evidence and practice that are pervasive in low-income, middle-income, and high-income countries. Different response strategies are needed that prevent and minimise disability and promote participation in physical and social activities. Here we highlight examples of effective, promising, or emerging solutions from around the world and make recommendations to strengthen the evidence base for them.

Section snippets

Prevention

By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate (table 1). Most of the widely promoted interventions to prevent low back pain (eg, work-place education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices) do not have a firm evidence base. A 2016 systematic review4 identified only 21 trials with 30 850 adults (one in a low-middle-income country [Thailand]),

Treatment

Low back pain without a known cause is referred to as non-specific low back pain and guidelines5, 6, 7, 8 recommend use of a biopsychosocial model to inform assessment and management in view of associations between behavioural, psychological, and social factors and the future persistence of pain and disability. Guidelines also recommend that laboratory tests and imaging should not be routinely used as part of early management, but rather reserved for patients for whom the result is likely to

The global gap between evidence and practice

Despite multiple clinical guidelines providing similar recommendations for managing low back pain, a substantial gap between evidence and practice exists worldwide in high-income as well as low-income and middle-income countries.23 Problems include both overuse of low-value care and underuse of high-value care. Panel 1 shows studies of clinical practice and highlights the disparity between ten guideline recommendations and the reality of current health care. Tremendous opportunity exists to

Promising directions

Examples of effective, promising, and emerging solutions that target health care, public health, or both, are summarised in table 3. We particularly searched for examples from low-income and middle-income countries but found very few assessments of solutions within these countries that suggest they might offer helpful alternatives to current care. More data are urgently needed about effective and affordable strategies for prevention and management of low back pain in such countries. In these

Implementation of best available evidence

That guidelines without effective strategies to implement their recommendations have little or no effect on clinical practice has been repeatedly shown. Implementation strategies need to be tailored to overcome specific barriers to change106 and feature education and training, social interaction, clinical decision support systems, and targeted reminders.107, 108 Some of the key challenges to implementing best practice for low back pain are known, including short consultation times, clinicians'

Clinical systems and pathways

A more radical health-care solution is to change the clinical-care model for low back pain. An example of this is a new model of stratified primary care for non-specific low back pain known as STarT Back that involves two components; first, a brief self-completed questionnaire to identify patients' risk of persistent disabling pain (low, medium, or high risk)86 and second, treatments that are matched to each risk subgroup. Summarised in table 3 are two studies within the UK's National Health

Integrate health and occupational interventions

A further promising direction could be to target both the health-care system and, more broadly, public health through integrated health-care and occupational interventions. If back pain symptoms are reduced, then return to work is expected to follow. The association between pain, function, and return to work is, however, weak with reviews suggesting that the association changes with low back pain duration (positive association in the acute phase, no association in the subacute phase, and

Conclusions

Despite many clinical guidelines with similar recommendations for the management of low back pain, the gap between evidence and practice is pervasive. We have provided examples of effective, promising, and emerging directions that deserve greater attention and more rigorous assessment. Even the solutions judged effective draw on limited evidence, but they could potentially be replicable and cost-effective in other settings. Focusing on key principles, such as the need to reduce unnecessary

Search strategy and selection criteria

We identified publications using broad search terms in PubMed and Scopus and based our examples on systematic searches of the published literature. To identify examples from low-income and middle-income countries, we additionally drew on experts in the team either based, or doing research, in these countries. The strength of evidence for the examples of the different solutions to the prevention and management of low back pain varied widely and, therefore, we have incorporated summaries of the

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