Low Back Pain: A Global Pandemic

leaps and bounds rehab Pat Stanziano MPT, SPD, Cert MDT, CSCS,by Pat Stanziano, MPT, Hons BSc Kin

 

  • Reg. Sport Physiotherapist (Dip SPC, IFSPT)
  • Cert. McKenzie MDT Practitioner (MIC)
  • Cert. Complete Concussion Management Practitioner
  • Cert. Strength and Conditioning Specialist

 

In my last blog post, Pain Rx: Get Movin’!, I discussed how the research points to movement and exercise, as really, the only stand alone therapeutic modality that a physical rehabilitation professional can provide in the efficacious management of acute and chronic pain.  I discussed the many therapeutic modalities that do more harm (not necessarily physical) than they do good.  Finally, in the attempt to become more active,  there may be other aspects of your life contributing to your pain that need to be addressed.  In a recent publication series by The Lancet, these points (and more) were stressed in the management of a global pandemic: Low Back Pain.

Here are the key points.

WHAT LOW BACK PAIN IS AND WHY WE NEED TO PAY ATTENTION

(Hartvigsen, J et al)

  • Low back pain is an extremely common symptom in populations worldwide and occurs in all age groups, from children to the elderly population
  • Low back pain was responsible for 60·1 million disability-adjusted life-years in 2015, an increase of 54% since 1990, with the biggest increase seen in low-income and middle-income countries
  • Disability from low back pain is highest in working age groups worldwide, which is especially concerning in low-income and middle-income countries where informal employment is common and possibilities for job modification are limited
  • Most episodes of low back pain are short-lasting with little or no consequence, but recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences
  • Low back pain is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and pain-processing mechanisms

 

Contributors to low back pain and disability

Figure 1 – Contributors to low back pain and disability

Figure 1 includes key contributors to low back pain and disability but does not attempt to represent the complex interactions between different contributors. *Nociceptive input includes non-identifiable sources in non-specific low back pain, neurological sources (eg, radicular pain) and specific pathology (eg, fractures).

  • For the vast majority of people with low back pain, it is currently not possible to accurately identify the specific nociceptive source
  • Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes
  • Costs associated with health care and work disability attributed to low back pain vary considerably between countries, and are influenced by social norms, health-care approaches, and legislation
  • The global burden of low back pain is projected to increase even further in coming decades, particularly in low-income and middle-income countries

 

 

PREVENTION AND TREATMENT OF LOW BACK PAIN: EVIDENCE, CHALLENGES, AND PROMISING DIRECTIONS

(Foster, N et al)

  • Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments; routine use of imaging and investigations is not recommended
  • Little prevention research exists, with the only known effective interventions for secondary prevention being exercise combined with education, and exercise alone
  • The evidence for prevention and treatment comes mainly from adults in high-income countries and whether the resulting recommendations are appropriate for children or those in low-income and middle-income countries is not known
  • Non-evidence-based practice is apparent across all income settings; common problems are presentations to emergency departments and liberal use of imaging, opioids, spinal injections, and surgery
  • Promising solutions include focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies
  • The evidence underpinning these solutions is inadequate and whether they are appropriate for widespread implementation is not known
  • Further testing of these promising solutions, and development of new solutions, is needed, particularly in low-income and middle-income countries

Gaps between evidence and practice in the management of low back pain

Guideline Messages:

  • Figure 2 - Standard reaction to lower back pain

    Figure 2 – Standard reaction to lower back pain

    Low back pain should be managed in primary care

  • Provide education and advice
  • Remain active and stay at work
  • Imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain
  • First choice of therapy should be non-pharmacological
  • Most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction)
  • Due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged
  • Interventional procedures and surgery have a very limited role, if any, in the management of low back pain
  • Exercise is recommended for chronic low back pain
  • A biopsychosocial framework should guide management of low back pain

 

LOW BACK PAIN: A CALL FOR ACTION

(Buchbinder, R et al)

Call for actions to meet the challenges associated with prevention of disabling low back pain

  • Political challenge: increase recognition of the effects and burden of back pain by international and national policy makers
  • Public health challenge: prevent onset and persistence of disability associated with low back pain
  • Health-care challenge: move away from emphasis on a biomedical and fragmented model of care

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a philosophy of active patient involvement and education that is trusted and used by clinicians and patients all over the world for low back, neck and extremity problems.  A key feature is the initial assessment – a safe and reliable way to reach an accurate diagnosis and then make the appropriate treatment plan.

Expensive tests such as MRI’s, low-value interventions like ultrasound/electric stimulation, and pharmacological agents are often unnecessary.  Certified MDT clinicians are able to rapidly determine whether the method will be effective for each patient.  

In its truest sense, MDT is a comprehensive approach based on sound principles and fundamentals that, when fully understood and followed, is very successful in managing your low back pain and helping you reach your performance goals.  

 

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