Tuesday, June 12, 2018

Current Evidence on Low Back Pain: The Lancet 2018


Low back pain is a “catch-all” diagnosis without a clear pathoanatomical source generator and treated in a plethora of ways ranging from medications, rest, manual care, traction, acupuncture, & exercise. But what does the current evidence tell us, both about diagnostics and treatment? More so, how is a clinician supposed to interpret the literature to produce meaningful outcomes with the patients they treat? Recently, The Lancet Low Back Pain Series Working Group published a series of articles focused on examining the current evidence surrounding low back pain to provide an understanding of low back pain and current evidence on its diagnosis and treatment. What was unique was that the articles looked at current practice in various countries around the world. To this point, I’d strongly encourage reading the articles to get a flavor for how differently low back pain is viewed and treated around the world. Below is my brief summary of the key points of these articles. 


Assessment

1.    Low back pain is now the number one cause of disability worldwide. It affected 60.1 million lives (yes, I said million) in 2015 alone. Disability was found to be highest in working age groups of low-mid socioeconomic status. Most episodes were found to be short lasting and self-limiting. The authors concluded that these numbers are expected to increase in low to middle income countries over the next few decades.

2.   The authors noted that the following:

a.   identifying source tissue was quite difficult with the use of MRI and other types of imaging. This was due to a large percentage of population who do not have any specific pain, despite having positive MRI findings, (e.g. disc bulges or facet arthritis). It was noted however, that Modic Type I (vertebral end plate changes associated with degenerative findings)  changes may be indicative of some type of back pain, as well as fractures, malignancies, or infections (although the prevalence of these were low).

b.   low back pain was multi-factorial with physical factors being influenced by co-morbdities (e.g. asthma, diabetes, obesity etc.), psychological factors, social factors, & genetics.

c. there is moderate evidence that a centralized pain process could occur in patients with chronic back pain.


With the above current findings, it is obvious to see why assessment of low back pain can be quite a challenge for even the most seasoned clinician. But what about treatment?

Treatment

The authors of the Low Back Pain Series Working Group looked at all the various types of care for low back pain with their recommnedations.


1.    First and foremost, they recommended that patients be initially treated non-pharmacologically and educated on their back pain.  The thought here was to overcome fear avoidance and dispel the idea of bedrest as a treatment.

2.    Patients should be encouraged to move and function within their day-to-day activities. For those who required more care, the recommendations again fell upon movement and graded exercise to nurse a patient back to health.
3.   Spinal manipulation, acupuncture, & massage may be beneficial in the short-term management of LBP, but there was not solid evidence to support long-term care. 

4.   For the patients who failed these forms of care, pharmacological care such as with NSAIDs were considered another treatment option or as an adjunct to current care. However, opioids were not recommended.  Patients who were prescribed opioids were encouraged to be monitored given the medication risks, which include addiction.

5.   Lastly, there were recommendations on spinal epidurals which were shown to be effective in only severe forms of radicular pain. Surgery was considered as a last resort in the face of neurological deficits or when all other conservative forms of care had failed.

What’s a clinician to do?


Being a Movement Links Clinician and instructor, I’m a big believer in the APTA’s 2020 vision of physical therapists as movement practitioners.   I was delighted to read that exercise and education are the forms of care currently endorsed as best practice. Although the articles do not specifically highlight which type of exercise or what specific muscle groups to target, it is important to note clinically that getting your patient to move, (and do so correctly) is paramount in managing their overall condition. Additionally, manual therapy can be included in the initial stage to assist a patient in getting back on track. 

Passive forms of care such as electrical stimulation, ultrasound, diathermy, or traction were not recommended or found to be effective in the management of low back pain.

That all being said, what direction should a clinician take in management of back pain? First and of utmost importance, a clinician should rely on sound clinical reasoning. Spending time clinically to actively listen to your patient and get a good understanding of what is going on with your patient can pay huge dividends.  Understanding the patient’s story can easily point the provider in the direction of where they need to go objectively and ultimately assist in the treatment of choice. Second, it is important to always take the WHOLE patient presentation into consideration. One point made from Foster et al’s article was the role that other co-morbidities play in patients with back pain. Here, the authors noted that patients with asthma, diabetes, headaches, & depression had a higher likelihood of having LBP.  Lastly, regardless of your clinical bias with regards to treatment approach, remember to educate your patient on the importance of movement and exercise, as well as a solid understanding of pain. Doing so will no doubt ensure that your patients are well on their path to recovery.


Jiten ( Jay ) Bhatt is a physical therapist at Kaiser Permanente Panorama City. He is a Movement Links Certified Clinician and instructor. Jay has been published in JOSPT and has presented at APTA CSM conferences. He is also a graduate of the Kaiser Permanente fellowship program.  
 


References


1.    Foster, NE, Anema, JR., Cherkin, D,  Chou, R, Cohen, SP, Gross, DP, Ferreira PH, Fritz JM, Koes BW, Turner, JA, Maher CG.  & Lancet Low Back Pain Series Working Group. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet.  https://www.ncbi.nlm.nih.gov/pubmed/29573872

2.  Hartvigsen, J., Hancock, MJ., Kongsted, A, Louw, Q, Ferreira, ML, Genevay, ., Hoy D,     Karppinen J, Pransky G, Sieper J, Smeets, RJ, Underwood M, Lancet Low Back Pain            Series Working Group.  (2018). What low back pain is and why we need to pay attention.     The Lancet.  https://www.ncbi.nlm.nih.gov/pubmed/29573870