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What Do We Really Know About Low Back Pain?

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     There are a lot of things I don’t know about low back pain. It is really tough to figure out what causes it. It is even tougher to develop an effective treatment plan. I don’t know why some people get better, but others have pain for decades. This uncertainty makes my job as a physical therapist much harder, considering the people I treat want to know the answers to these questions. The absence of certainty isn’t from the lack of trying. While it is hard to quantify exactly how much research has been done, low back pain has been studied extensively. A preliminary search on PubMed, a website indexing medical research, shows that there are over 15,000 studies with low back pain in the title.
What do we know for sure about low back pain? How do we know this information? More importantly, what information should you trust? It is not hard to do a quick google search on treatments for low back pain, and get a diverse array of opinions on why it is happening and what you should do to make yourself better. Because we don’t have solid answers, there is room for debate and discussion. This makes it nearly impossible for the average person to get reliable information.

     Low back pain is a topic that cannot be adequately explored in one blog post, and as such, much of my future content will focus on it. Here, I will provide a broad overview of low back pain research, as well as provide the most recent evidence-based guidelines for managing it. 

The Lancet Series On Low Back Pain

     The research on low back pain is dense, diverse, and difficult to quickly summarize. Many questions have been asked, many treatment approaches have been investigated, and much confusion and debate has been generated. While there is plenty of discussion to be had about low back pain research, I only want to present the results of two papers. These papers were published in a highly-respected and often-cited medical journal; The Lancet.

     The authors of these papers sought to discuss all things low back pain: risk factors, causes, treatments, social and political factors, and directions for change going forward. As this ambitious goal requires, they took a broad view of the low back pain research, summarized its findings, and identified things that all healthcare professionals can do better. I want to highlight a few key messages from these papers that low back pain sufferers should know. Each of these points can be an blog post on its own, and each has its own supporting evidence highlighted in the papers, but I will only go into each briefly.

  • For the majority of low back pain cases, it isn’t serious and will likely resolve on its own. Although numbers vary depending on which study you read, serious causes of low back pain like fractures, cancer, or other diseases are only found in a very, very small percentage of people with low back pain. Numbers vary from 1% to 5%. Most cases of acute back pain will resolve with time, and recurrence does happen, but statistically, your back pain is not likely to be a problem for long.
  • Imaging for back pain can be misleading, sometimes harmful, and is not recommended initially. It may be tempting to want to immediately get an x-ray or MRI of your back. Back pain can be debilitating, and you just want to figure out what is happening. Unfortunately, a rush to get imaging done can do more harm than good. As stated before, most of the time, the back pain you have is not due to something serious that would need to be addressed directly. In addition, the correlation between what a doctor would find on imaging, and the symptoms and course of your back pain is at the very least, fuzzy. While there is some correlation, a significant percentage of people will have an “abnormal” finding without having any symptoms at all. Also, as the authors point out, we don’t have evidence to suggest that early imaging can change the course of care or that it gets people better, faster. Lastly, for some people with special considerations, seeing an abnormal x-ray or MRI can contribute to harmful, untrue beliefs about low back pain that will negatively impact their course. For these reasons, it is actually better to hold off on getting an x-ray or an MRI performed until later in the course of care or if things are not getting better.
  • We probably can’t identify exactly what structure is causing your low back pain. You may have heard that back pain might be caused by something going wrong with the intervertebral disc, or the joints of the spine, or the nerves near the spine, or the surrounding muscles or something else. In school, we learned different physical tests to perform on patients to help determine what structures in their back might be causing their pain. Two years into clinical practice, I have completely abandoned them. These tests just aren’t that good at doing it. Pain is influenced by too many other factors, including psychological and social factors, to be an indicator of what structure is injured. As the authors point out, for most people with low back pain, identifying the specific structure that is causing your pain is not possible. And the truth is, it doesn’t really matter anyway. The treatment is still guided by movement and exercise that feels good and builds resilience.
  • We don’t really know how to prevent low back pain, but exercise and education might help. It makes sense that we would want to prevent low back pain before it starts; its debilitating and results in significant disability. Unfortunately, we just don’t have a lot of studies to point to that suggest effective methods for prevention. According to the Lancet authors, we do know that back belts, insoles, and workplace ergonomic interventions don’t work. Exercise and education might help with prevention, but it is something that we need to study more.
  • For acute low back pain, the only well-supported treatments are staying active and education. I have had many patients with the same story. They were bending over or lifting something up, heard a crack, and had immediate, severe back pain. Working with these patients can be challenging because there isn’t really much that I can do to help them, aside from reassuring them that they will get better with time and reminding them to stay active. Some things might feel good like using a heat pack, acupuncture or massage. Some exercises might help too. And some prescribed medication might help take the edge off. But the truth is, regardless of what you do after an episode of acute back pain, most people end up in the same place after a certain period of time. There is no good evidence that anything besides staying active and education about the condition helps with people with acute back pain.
  • For chronic low back pain, exercise and education are the most well-supported treatments. Exercise and education form the basis of treatment for pain that has lasted more than 12 weeks. Many approaches to exercise for low back pain have been put forth, including general stretching, general strengthening, core strengthening, cardiovascular exercise, yoga, and countless others. While the research suggests there are modest effects for each, there is no one clear winner as to what type of exercise is best. It may seem disheartening to know that we haven’t been able to find the best treatment, but it may be useful to remember that many different types of exercises can be effective for low back pain, and you should do something that is fun, enjoyable, and makes you feel strong and healthy.
  • Other treatments are secondary, not well-supported, or have evidence that shows they are ineffective. Many other treatments have been put forth for low back pain that haven’t been shown to be very helpful. The authors recommend things like acupuncture, massage, and spinal manipulation to be secondary treatments, while other treatments like injections, medications, and surgery are cautioned against and only helpful for some patients. Other treatments like electrical stimulation, ultrasound, and diathermy, practices common among physical therapists, have been conclusively shown to be ineffective and cannot be recommended.
  • Low back pain needs to be addressed within a biopsychosocial framework. Back pain has been traditionally thought of as a purely biomechanical problem; in the same way a mechanic would fix your car, physical therapists and other healthcare practitioners would fix your back. But recent research has illuminated other factors besides muscles, bones, joints, and discs can play a role in the clinical course of back pain. Psychological factors such as depression, anxiety, and maladaptive beliefs about back pain can exacerbate symptoms and extend the duration of a back pain episode. In addition, social factors such as access to accurate health information, health literacy, poverty, and even the country you live in can impact the care you receive. All of these factors need to be considered and optimized in order to appropriately address back pain.
  • Healthcare practitioners do not follow the best evidence. This is probably the most upsetting point of all. According to the authors, significant percentages of healthcare practitioners do not offer the most well-supported treatments. Bed rest, medication, surgery, alternative medicine treatments, and other passive things like electrical stimulation are still routinely suggested, despite evidence against them. I see this daily in my own profession. There are many reasons for this disparity, including difficulty accessessing, interpreting, and implementing new research, financial motives that can cloud judgment, and the arduous task of correcting decades of tradition. Myself and many others in my profession are working on it.

A Challenge For Patients And Us

      Some of the most challenging clinical scenarios I have encountered have involved patients with low back pain. Despite what confident healthcare practitioners might tell you or the latest headline on a popular media site, treatment can be complex, requires a multifactorial approach, and is not always successful. There are no quick fixes or simple cures. And I know this article didn’t answer all of your questions. There is much more to write about, and this article only serves as an introduction. In order to get the best treatment for your back pain, you must understand these points, and see a healthcare practitioner that does too. Lastly, I want to thank the authors of The Lancet papers who dedicate their time and attention to making things clearer.

References

  1. Foster, Nadine E, et al. “Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions.” The Lancet, vol. 391, no. 10137, 2018, pp. 2368–2383., doi:10.1016/s0140-6736(18)30489-6.
  2. Hartvigsen, Jan, et al. “What Low Back Pain Is and Why We Need to Pay Attention.” The Lancet, vol. 391, no. 10137, 2018, pp. 2356–2367., doi:10.1016/s0140-6736(18)30480-x.

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