What is the World’s Most Disabling Condition?

 

Introduction

The Lancet’s Low Back Pain Series Working Group published today’s definitive paper for summarizing the condition we call non-specific low back pain (LBP) (1). 

Their 12-page, fact-packed report titled “What Low Back Pain Is and Why We Need to Pay Attention,” might be best summarized with one quote: “Low back pain is a symptom, not a disease.” Then what is it, and would this understanding lead us to turn the tide against the world’s most disabling condition?

Epidemiology of Back Pain

Low back pain affects almost all ages, from teens to the elderly (2). Prevalence rises with age. On any given day, 7.3% of the population suffers from activity-limiting LBP. This makes LBP the world’s number one cause of disability (3).  What’s worse is that LBP is on the rise. From 1990 to 2015, years lived with LBP disability rose 54%. The personal, social, and economic burden represents an imperative for healthcare systems.

The Mechanism of Low Back Pain

Most LBP is dubbed non-specific. Nicholas Henschke and colleagues from the University of Sydney studied 1,172 consecutive LBP cases presenting to primary care (4). Of those, 0.9% could be attributed to specific causes such as fractures or malignancies. Of course, this means, in practice, it’s uncommon that a specific lesion or pathology is identified. Furthermore, there is little medical consensus for what LBP is. Some association has been found with certain MRI findings, such as bulging disk, but The Lancet Group could not find enough evidence to indicate these findings would be causal or even predictive. The most important risk factor in predicting LBP recurrence is a previous bout of LBP, suggesting that LBP itself is the indicator for an assertive LBP prevention program (5).

Three previous studies have connected LBP with deconditioning of the low-back multifidi muscles (6-8). The multifidi alone provide 2/3 of spinal stability in the low back (9), and multifidus atrophy has long been associated with poor functional outcomes of back surgery (10,11). Muscle deconditioning evident in imaging was not included in the Lancet Group’s study.

The Course of Low Back Pain

However, The Lancet Group affirms this evidence-based conclusion: LBP is a long-lasting condition with a variable course rather than episodes of unrelated occurrences. This underscores the importance of avoiding the temptation to think of LBP as an injury that will heal with time and protection. LBP episodes come and go, with 65-77% of patients surveyed experiencing pain 12 months after initial healthcare encounters (11,12). Most LBP expenses stem from recurrence (13), so the treatment goal must be long-term improvement in addition to resolving the current acute episode.

The Best Treatment for Low Back Pain

The best evidence we have points to physiotherapy as the first-line treatment. Patients managed passively have nearly triple the recurrence rate compared to patients receiving physiotherapy (7,8). Supervised physiotherapy proves superior to consultation and home exercise programs both in short-term and 52-week follow-up (14,15). Even with initial guidance from a healthcare professional, self-care alone produces insignificant results (16). Immediate access to physiotherapy has been shown cost-effective at improving quality of life and curbing other healthcare spending such as imaging, injections, and oral analgesics. Immediate access to physiotherapy improves outcomes and proves more cost-effective than waiting strategies (17,18).

While physiotherapists seem to be the ideal clinicians for treating LBP, The Lancet Group offers an important cautionary tale. Despite being the most trained in the approved exercise therapy programs, research suggests high use of disproven treatments such as lumbar traction and electrical modalities (20). For instance, a survey published in 2016 found that up to 34% of Australian physiotherapists advocated electrical modalities for LBP, despite these modalities being proven ineffective (21). Fortunately, this concern does not apply at Advanced Physiotherapy. We do not use these disproven treatments, and we stay abreast of the research and guidelines to provide the most effective treatments for our patients. 

 

References

1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ. What low back pain is and why we need to pay attention. The Lancet. 2018 Jun 9;391(10137):2356-67.
2. Kamper SJ, Henschke N, Hestbaek L, Dunn KM, Williams CM. Musculoskeletal pain in children and adolescents. Brazilian Journal of Physical Therapy. 2016 Feb 16;20(3).
3. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, Carter A, Casey DC, Charlson FJ, Chen AZ, Coggeshall M. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016 Oct 8;388(10053):1545-602.
4. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 2009 Oct;60(10):3072-80.
5. Taylor J, Goode A, George S, Cook C. Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. Spine J. 2014; 14 (10): 2299-319.
6. Sions J, Coyle P, Velasco T, et al. Multifidi muscle characteristics and physical function among older adults with and without chronic low back pain. Archives of Physical Medicine and Rehabilitation. 2017; 98: 51-7.
7. Hides J, Gwendolen A, Richardson C. Long-term effects of specific stabilizing exercises for first episode low back pain. Spine. 2001; 26 (11): pp e243-248