Research Review By Dr. Demetry Assimakopoulos©

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Date Posted:

July 2018

Review Title:

Lancet Low Back Pain Series – Part 2 – Prevention & Treatment

Paper Reviewed:

Foster NE, Anema JR, Chou R et al. Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions. Lancet 2018; 391(10137): 2368-2383. http://dx.doi.org/10.1016/S0140-6736(18)30489-6

Author's Affiliations:

Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands; Kaiser Permanente Washington Health Research Institute, Seattle WA, USA.

Background Information:

The burden of low back pain (LBP) and back-related disability have increased, in spite of the large investment of healthcare resources into its treatment (1, 2). The additional two papers in this important Lancet series (reviewed separately) described the global burden of LBP and examined its potential etiology and clinical course. This third paper in the series endeavoured to summarize the multitude of LBP practice guidelines, and the evidence for prevention and treatment of LBP. The authors also attempted to highlight examples of effective, promising or emerging solutions to the global burden of LBP.

Summary:

Prevention of Low Back Pain (LBP):

There is unfortunately very little published about LBP prevention. Multiple potentially preventive interventions are recommended, such as work-place education, no-lift policies, ergonomic furniture, mattresses, back belts and lifting devices, despite a lack of robust evidence in their favour. One large systematic review (3) concluded that exercise alone, or in combination with education, is effective for prevention (pooled relative risk [RR] = 0.55). Unfortunately, the included studies in that particular systematic review (3) took place within secondary prevention settings and are thus poorly generalizable to primary care.

Overall, there is poor to very-poor quality evidence suggesting a lack of effectiveness of education, back belts, shoe insoles and ergonomic programs (4, 3) for the prevention (or treatment) of LBP. Further, very little evidence exists for or against any LBP prevention strategy in children.

Treatment of LBP:

Guidelines on the assessment and management of non-specific LBP recommend the use of a biopsychosocial paradigm to inform decision making (3, 5-7). The guidelines also stipulate that laboratory testing and imaging should not be routinely used as part of early management and should be reserved only for patients in which these assessment strategies may change pain management (i.e. those with suspected cancer, inflammatory conditions, etc.).

LBP management guidelines are now placing greater emphasis on self-management, physical/psychological therapies, and some forms of complementary medicine, with less emphasis on pharmacological and surgical treatments. Various guidelines recommend that non-pharmacological treatments such as massage, acupuncture, SMT, Tai Chi and yoga be utilized as first line therapies. Multiple guidelines also consistently recommend that patients should be thoroughly educated about the nature of LBP, reassured that symptoms will improve over time, encouraged to avoid bed rest, and to stay active and working. They additionally recommend that pharmacological interventions be reserved for patients who fail conservative care. Early, supervised exercise therapy is typically not necessary, but can be considered if recovery is slow or if individual patients carry risk factors for persistent disability and pain. The recommendations are the same for cases of acute radiculopathy, as data are insufficient to suggest whether initial management should differ.

Graded activity/exercise targeting functional prevention of disability are recommended for patients suffering from chronic LBP (> 12 weeks). Exercise should be prescribed based on the patient’s individual needs, preferences and capabilities, as studies have failed to experimentally identify one superior form of exercise.

Some guidelines suggest against the use of passive therapies such as SMT, mobilization, massage and acupuncture, while others advise a trial of passive care in individual patients. Modalities such as ultrasound, TENS, IFC, short-wave diathermy and back supports are consistently not recommended (5-7). Guidelines also recommend psychological therapies (i.e. cognitive-behavioral therapy [CBT], relaxation, mindfulness) or a combination of physical and psychological therapies for individuals that have failed to respond to previous treatments (5-7). Multi-disciplinary programs providing a variable combination of supervised exercise, CBT and pharmacotherapies are more effective than standard treatments for complex chronic cases.

Pharmacological treatments are reserved for those who fail to respond to first-line treatments. Paracetamol was previously recommended as a first-line pharmacotherapy for LBP. However, more recent evidence has shown Paracetamol is ineffective and it carries a potential for harm (6-8). As such, a short-course of NSAIDs should be trialed rather than Paracetamol (7). Routine use of opioids should only be carefully utilized in select patients, for a short duration with appropriate monitoring, and otherwise not trialed since benefits are small and substantial risks exist. The use of Gabapentinoid drugs like pregabalin are now being reconsidered, after a 2017 trial showed pregabalin to be ineffective in the management of radiculopathy (9). Guidelines also suggest consideration of short-term use of muscle relaxants, although more research is needed.

Recent guidelines do not recommend use of epidural or facet joint injections for back pain (5, 7), but do endorse the use of epidural injections for severe radicular pain (7). These recommendations are based on the evidence demonstrating that epidural injections only provide small short-term pain relief (< 4 weeks, typically), and fail to provide long-term benefit or reduce the risk of surgery (5, 10). Although rare, epidural injections are also associated with potentially serious adverse events, including loss of vision, stroke, paralysis and death (11). Use of radiofrequency denervation for chronic low back pain that is unresponsive to non-surgical treatments has been advocated by some (7), but not others (12).

The benefits of spinal fusion surgeries for discogenic, degenerative, non-radicular LBP are similar to intensive multi-disciplinary rehabilitation; and perform only slightly better than standard non-surgical management. The risks, cost and number of adverse events of fusion surgery are also far greater than those for non-surgical management. As such, spinal decompression surgery should be reserved for those with severe or progressive neurological deficit, or when non-surgical treatments for radicular pain have failed.

The Global Gap Between Evidence and Practice:

A large gap exists between evidence and practice in low-, middle- and high-income countries. Data from Australia and Qatar have shown that advice to keep patients active and at work are provided in only very few consultations. Further, a multitude of American studies have shown that only half of those with CLBP are prescribed exercise. Another glaring and potentially fatal example guideline-discordant practice are data showing that opioids are prescribed in approximately 60% of LBP cases presenting to American emergency departments! These and other examples are ongoing symptoms of the continued waste of healthcare dollars and high patient costs in terms of radiation exposure, work absence, opioid-related deaths, wound complications, cardiopulmonary complications, mortality and a lack of positive clinical outcomes. The world is finally starting to realize the mess we have created via mainstream management strategies for LBP!

Implementation of Best Evidence:

Implementation strategies need to be tailored to overcome specific barriers to change. These strategies must include education and training, social interaction, clinical decision support systems and targeted reminders. Challenges to implementing best practices include: short consultation times, lack of clinical knowledge, fear of litigation and desire to appease patients. Fortunately, successful examples of guideline implementation do exist. In the UK and USA, special radiograph requisition forms that only allowed three guideline-appropriate indications led to a 36.8% reduction in lumbar spine imaging. Also, the addition of short educational messages to all outgoing lumbar spine MRI reports significantly reduced imaging rates by 22.5%. Implementation strategies require repetition to effectively enable change in clinical practice.

Improved and better-integrated education of healthcare professionals could support implementation of best practice for LBP, break down professional barriers, develop a common language and create innovative strategies for practice (13). Examples of this include integrated education of medical and chiropractic students in Denmark, and the successful training of Swedish physiotherapists in identifying and addressing psychosocial obstacles to recovery in patients with LBP (14).

More radical solutions are needed to change the clinical-care model for LBP. An example includes the development of stratified primary care for non-specific LBP – known as the STarT Back Tool. This tool is comprised of two components:
  1. A brief self-completed questionnaire to identify an individual patient’s risk of developing persistent pain; and
  2. Treatment(s) matched to each risk sub-group.
This type of stratified care is more effective than a base care comparison group (15) and more cost-effective than usual primary care (16). The UK guidelines now recommend risk-stratification.

Another potential health-care solution may be to reconfigure the whole clinical pathway of care from first contact in the primary setting to specialized care. An example of this is Canada’s Saskatchewan Spine Pathway, which aims to use multi-disciplinary care to reduce MRI requests and spinal surgery referrals (17). A major barrier to this relates to current models of healthcare reimbursement, which reward volume over care quality (18).

Another emerging direction could be to target both healthcare and public health through integrated healthcare and occupational interventions. While it is expected patients to return to work once pain improves, the association between pain, function and return to work is weak. It is well-established that people can improve in function and return to work even if pain remains, and that return to work occurs before symptom recovery (19). This implies that healthcare and occupational health interventions should be intertwined. Data from the Netherlands show that participatory return-to-work programs have doubled total return to work rates and enabled earlier return to work compared to usual care.

Public health approaches offer a possible solution. Mass-media campaigns have shown success in four high-income countries. These campaigns are more successful when they have a clear focus on behaviours rather than beliefs alone and incorporate new ways to disseminate information (i.e. personalized marketing, social networks and customized digital communications). We certainly have a lot of work left to do in terms of how we educate the public about LBP!

Clinical Application & Conclusions:

The authors of this paper sought to synthesize the various recommendations for the management of low back pain. Recommendations spanned from conservative-care to interventional and surgical care. They also discussed examples of effective, promising and emerging solutions to the worldwide LBP crisis, and to improve knowledge transfer of guidelines to clinical practice. They concluded that no single specific proposed solution will be effective without collaborative efforts from patients, policy makers, clinicians and researchers alike.

Below are the key messages that readers should take away from this article:
  1. The majority of clinical guidelines recommend self-management, physical and psychological therapies and some CAM therapies for LBP – this is great news for chiropractors, physiotherapists and other conservative clinicians! They also now place less emphasis on pharmacological and surgical treatments. Routine use of imaging and advanced investigations are not recommended.
  2. Very little prevention research exists. The only known secondary prevention intervention is regular exercise +/- education. More research is needed in this area.
  3. The evidence on treatment and prevention is mainly from adult populations in high-income countries. Whether these recommendations are appropriate for children or patients in middle-to-low-income countries is unknown.
  4. The use of non-evidence-based practice methods continues, regardless of income setting. The most common problems relating to LBP include: presentations to emergency departments, liberal use of imaging, opioid prescription, spinal injections and surgery.
  5. Solutions for these issues could be to provide focused implementation of best practice, redesigning of clinical pathways, integration of health and occupational care, make changes to payment systems and legislation, and to enact large public health prevention strategies. Unfortunately, the evidence underpinning these solutions is inadequate.
  6. Further testing of these promising solutions and development of new solutions is needed, especially in middle- and low-income countries.

Study Methods:

The authors identified pertinent studies using broad search terms in PubMed and Scopus, and through asking experts practicing or performing research within middle- or low-income nations. No statistical analyses were performed.

Study Strengths / Weaknesses:

These authors essentially provided a proverbial “State of the Union” by discussing the evidence for the entire spectrum of low back pain treatments. They advocated that different treatments may be best at different times for individual patients, without bias towards a specific profession (what a concept!). It is amazing to see such a collaborative effort between international institutions and professions. Unfortunately, in many ways, specific recommendations could not be made in middle- and low-income nations, as more evidence needs to be collected in these regions.

Additional References:

  1. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med 2009; 169: 251−58.
  2. Hoy D, March L, Brooks P, et al. Measuring the global burden of low back pain. Best Pract Res Clin Rheumatol 2010; 24: 155−65.
  3. Michaleff ZA, Kamper SJ, Maher CG, Evans R, Broderick C, Henschke N. Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J 2014; 23: 2046−58.
  4. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016; 176: 199−208.
  5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60–75.
  6. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. 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: 514−30.
  7. UK National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. November 2016. https://www.nice.org.uk/guidance/ng59 (accessed Nov 7, 2017) .
  8. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015; 350: h1225.
  9. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med 2017; 376: 1111−20.
  10. Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med 2015; 163: 373−81.
  11. US Food and Drug Administration. Drug safety communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. 2014. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM394286.pdf (accessed Nov 7, 2017) .
  12. Juch JNS, Maas ET, Ostelo R, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA 2017; 318: 68−81.
  13. Myburgh C, Mouton J. The development of contemporary chiropractic education in Denmark: an exploratory study. J Manipulative Physiol Ther 2008; 31: 583−92.
  14. Overmeer T, Boersma K, Main CJ, Linton SJ. Do physical therapists change their beliefs, attitudes, knowledge, skills and behaviour after a biopsychosocially orientated university course? J Eval Clin Pract 2009; 15: 724−32.
  15. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560−71.
  16. Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med 2014; 12: 102−11.
  17. Kindrachuk DR, Fourney DR. Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization. J Neurosurg Spine 2014; 20: 87−92.
  18. Fuhrmans V. Withdrawal treatment: a novel plan helps hospital wean itself off pricey tests. The Wall Street Journal (New York). Jan 12, 2007.
  19. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008; 337: a171.