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Prevention and treatment of low back pain

Research has found that some of the treatments offered for low back pain are often contrary to the evidence of what is effective and indeed to the guidelines advocated by public health authorities. They were found to be unnecessary and expensive and not offering long lasting benefits.

There is moderate evidence that education, or education in combination with exercise is effective for the prevention of low back in adults, although there is very little evidence for children.  For most people, low back pain, is not a serious condition. Their symptoms will usually improve and they should be reassured and advised to avoid bed rest and to carry on with their usual activities, including going to work.

Despite the guidelines for many public health authorities in the western world advocating this approach, the practice is very different. Many people are offered drug intervention, rather than education and advice, at their first visit to a medical practitioner despite the evidence showing it to be ineffective. Paracetamol is not now advised because research has shown it doesn’t improve symptoms. Opioids are not recommended unless for a very short time with careful monitoring because of their side effects. Non-steroidal anti-inflammatories can be considered, taking into account their risks but should be given at the lowest dose for the shortest time. Lab tests and imaging such as X-rays and MRIs are often unnecessary unless the practitioners think it will change the course of the treatment, if for instance they suspect infection.

There is insufficient evidence for the benefits of spinal epidurals or facet joint injections apart from local anaesthetic or steroid injection for severe radicular pain. Surgery to replace discs or fuse the spine are not recommended for low back pain apart from those who have severe or worsening neurological symptoms. In high income settings there is a high incidence of expensive surgery. There is also little evidence for ultrasound, traction and interferential therapies.

There is evidence that spinal manipulation, massage and acupuncture have some benefits as an additional treatment to exercise and advice. Exercise therapy and graded activity has been found to be helpful though there is no evidence for one type of exercise over another. It is therefore helpful for the practitioner to discuss with the patient their particular preferences and capabilities. Exercise is recommended for chronic low back pain although it is rarely given, especially in the US, where 54% of people with chronic low back pain were not advised of its benefits.

The guidelines and the evidence point to the value of talking therapies such as cognitive behaviour therapy (CBT) and mindfulness approaches for those who have not responded to first line treatment however, research found in the US only 8.4% of those with chronic low back pain and depression had seen a psychiatrist or psychologist in the last year.

Prof Nadine Foster et al “The Prevention and treatment of low back pain: evidence, challenges and promising directions” The Lancet 21st March 2018.