by Jay Bhatt, DPT, OCS
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.
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.
Picture from "Complete Anatomy" app
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.
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 recommendations.
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.
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
