Review of The Lancet Article: Prevention and treatment of low back pain: evidence, challenges, and promising directions (Part Two)
On the Chiropractic Forward podcast this week, we are going continue a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow. This week it will be a review of paper #2 from the Lancet series called Prevention and treatment of low back pain: evidence, challenges, and promising directions.
Before we get started, I want to draw your attention our website at http://www.chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.
Welcome to the podcast today, you have strolled right into episode 17. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go.
As I mentioned at the top of the show, this week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap this week…. The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain, prevention of low back pain, and treatment of low back pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors.
Essentially, EVERYONE had a seat at the table so, it is the general consensus at this point that this series of papers is as current, as credible, and as accurate as can be had at this point in time and in our understanding of Low Back Pain.
The three papers were broken down as follows:
- What low back pain is and why we need to pay attention.
- Prevention and treatment of low back pain: evidence, challenges, and promising directions.
- Low back pain: a call for action.
Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process.
We will do the same this week with the second paper of the series titled, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”
I want to start this week in the same way we started last week: by discussing how the papers were accomplished.
How They Did It
For this paper, again titled “Prevention and treatment of low back pain,” the researchers identified scientific studies through searches of databases:
•African Index Medicus Database
In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.
Paper 2 Summary:
Recommendations commonly offered for those with low back pain include:
- Pharmacologic implementation is not typically a first line choice
- Education supporting self-management
- Resumption of regular daily activities
- Resumption of exercise
- Psychological programs for those with low back pain that tends to linger
- Limited or non-use of medication
- Limited or non-use of imaging
- Limited or non-use of surgery
The authors state that these recommendations for prevention and treatment of low back pain are derived from high-income countries and that they are concentrated on treatment rather than preventative recommendations.
The authors state there is an inappropriate high usage of the following treatments for low back pain:
- Spinal injections
The authors also say that doing a lot of the same will get us the same results so, in going further, the treatment of low back pain should be more in line with what evidence suggests is effective. Things like exercise and getting back to work as soon as possible. Makes sense to us!
In the rest of the paper, the authors identify some promising directions and solutions for treatment of low back pain including the redesign of clinical pathways, an integrated health partnership, and occupational interventions to get workers back when possible.
- A 2016 systematic review with 30,850 adults showed that there was moderate quality evidence that exercise alone, or in combination with education, is effective for prevention of low back pain.
- However, the review was mainly for secondary prevention and the exercise program required an intense schedule of twenty 1-hour supervised sessions.
- A 2014 systematic review with 2700 children that found moderate quality evidence that education is not effective. They also found that ergonomic furniture was likely no more help in preventing low back pain than regular furniture.
Some key messages for Prevention were self-management, physical and psychological regimens, and some forms of complementary medicine
In regards to Treatment, there should be less emphasis on pharmacologic protocols and less instances of surgical intervention. Also, the authors write that, although their popularity in healthcare has been steadily on the rise, there should be less utilization of imaging, opioids, and spinal injections.
The authors cite three studies. The studies come from Denmark, the UK, and the USA.
- All three of the studies (Danish, UK and USA) recommend spinal manipulation as an effective treatment of low back pain. The UK study specifically recommends spinal manipulation in conjunction with an exercise protocol.
- As my own side note, in America, chiropractors perform 90% of all spinal manipulations. When we are discussing spinal manipulation and it’s role in treating low back pain, it is important to keep in mind which profession is the one being recommended. Although the authors do not come out and recommend chiropractic specifically, when spinal manipulations are recommended, it is a well-known fact that chiropractors are the doctors that are best-equipped to perform the treatment.
- Also in the US guidelines, there is a recommendations for the marked reduction of pharmacologic care.
- Some key advice coming from these updated recommendations (besides the use of spinal manipulation) is to assure patients they are not suffering from serious disease, that they will indeed improve in time, that they should continue as much movement and exercise as can be tolerated, they should avoid bed rest, and they should get back to work as soon as possible.
- The authors recommend physical treatments. Certainly for chronic low back pain which refers to pain lasting longer than 12 weeks. Physical treatments included exercise programs targeting the patients’ abilities, preferences, etc.
- The authors stated that passive therapies such as electric stim, interferential, traction, diathermy, and back supports seem to be ineffective. As a side note, it’s strictly anecdotal but this panel of experts are going to have a hard time convincing me traction, when done correctly, is not effective. I’ve seen patients avoid surgery from traction therapy alone.
- They say new recommendations encourage doctors consider psychological therapies such as cognitive behavior therapies, progressive relaxation therapy, and mindfulness-based stress reduction alone or in combination with other physical and psychological treatment for chronic low back pain with or without radiculopathy having not responded to other treatments.
- If the condition persists and the patient is functionally disabled, the authors then recommend multidisciplinary rehab with supervised exercise, cognitive behavior, and medication.
- Of course, routine use of opioids is not advised.
- Recommend no spinal epidural injections or facet joint injections for low back pain
- Do recommend epidural injections of local anesthetic & steroid for radicular pain, however, as we have discussed before, epidural steroid injections show short-term effectiveness only if they are effective at all and have no influence at all on long-term disability or future need for surgery. In my own research, epidural steroid injections have shown to increase risk of spinal fracture up to 21% after each subsequent injection.
- Surgery – the benefits for spinal fusion when the back pain was thought to be due to degenerated discs were about equal to the results gained with intensive multidisciplinary rehab and only a modest improvement over non-surgical treatment. In addition, surgery has obvious downsides like expense, recovery, medication, and the risk of adverse events. However, surgery may be indicated when the patient is suffering severe or progressive neurological symptoms and surgery may be indicated when patients suffer radicular pain, have failed first line treatment, and the symptoms can be traced to via imaging to a disc or stenosis origin.
- Ultimately, the authors say, low back pain patients have a tendency to resolve with out without surgical intervention so waiting and trying to avoid surgery is certainly appropriate.
- Research dealing with low back pain in children or in low and middle income countries is limited so a lot is unknown for those categories, however, the two studies that actually have been done in low and middle income countries (Brazil and Philippines) have similar results as those in high income countries.
The global gap between evidence and practice
This section masterfully demonstrates the difference between evidence-based medicine and what is really happening in the real world.
When it comes to low back pain, the medical field is not adhering to research globally as they “overuse low-value care and underuse high-value care.”
- They start by stating that low back pain should be managed by primary care practitioners and then go on to list studies showing how it is being managed, in many cases, by emergency rooms, hospitals, and surgeons.
- Their next directive is to provide low back pain patients with education and advice on self management and then show how, in the real world, roughly only 20%-23% of practitioners seem to actually do so.
- The next directive is for low back pain patients to stay active and get to work or stay at work if possible. They go on to cite research showing how, in the real world, medical professionals are recommending rest and time off work. In India, for example, 46% of physiotherapists recommended rest to low back pain patients and in Brazil, rheumatologist recommended rest.
- The next comparison was for the guideline that imaging should only be ordered if the practitioner suspects a specific cause that would guide treatment and case management differing from normal care recommendations. In the USA, for example, from 2010-2013 the rate of imaging the low back with no red flags stayed consistent at 53.7%. If we thought that was excessive, the authors go on to cite information from India showing 100% of chronic low back pain patients in an orthopedic clinic underwent imaging for non-specific low back pain. Similar results were found through the other studies cited for low and middle income countries.
- The next comparison was for the guideline that the first line treatments should be non-pharmacologic. They found that this guideline is not commonly followed citing research for high income countries demonstrating that 64.5% of low back pain patients in Australia from 2000-2010 were prescribed meds on the first visit and, on a personal note, I had a patient here in the USA just this morning with acute low back pain that was prescribed pain meds on the first day. To be fair, his pain is severe but, they are not following guidelines and the meds have had no impact on his level of pain still he continues to take them as ordered. Medication for no effect essentially. In the lower and middle-income countries, the authors cite research showing that in South Africa, 90% of the low back pain patients going to a primary care physician received medication.
- The next guideline was that many times, there was advice to avoid electrical physical modalities such as diathermy, etc. In the high-income setting, Swedish physiotherapists recommend transcutaneous stim for low back pain to the tune of 38%, 75% of American PTs use lumbar traction, and a Spanish National Health Service study suggested 38.6% of physical therapy costs were for treatments known to have no effectiveness.
- The next guide comparison was that the use of opioids is discouraged. The authors go on to cite prescription rates from 2004-2009 and, to be honest, I think the opioid epidemic has likely caused the numbers cited to actually drop. Although opioid addiction is on the rise, it’s my opinion that it is now at the forefront of the national story. With the sort of attention it has demanded, I cannot imagine the numbers staying the same. That is my opinion, of course.
- Next guide was that surgery and interventional treatment should be very limited or possibly eliminated for low back pain. In the real world, this is not occurring. In the USA in 2011, spinal fusion was the reason for the most costs of any surgical procedure in the nation. US Medicare covered 2,023,481 epidural injections (a substantial increase from 2000-2011), 990,449 lumbar or sacral facet injections as well as 406,378 lumbar or sacral facet neurotomy treatments, Medicare funded 252,654 sacroiliac joint injections. Two-thirds of Dutch spinal surgeons perform spinal fusion surgeries.
- The next guide comparison was that exercise is now recommended for the treatment of chronic low back pain. A 2009 paper the authors cited showed that 54% of Americans with chronic low back pain were not prescribed any exercise as treatment.
- The final guide comparison was done for the recommendation that a biopsychosocial framework guide the management for low back pain patients. In the USA, only 12% of chronic low back pain patients had been treated for their diagnosed depression in the year prior and only 8.4% were recommended cognitive behavioral treatment.
implementation of the best available evidence
The authors state here that some of the biggest issues toward implementation of new low back guidelines may be short consultation times, the practitioners having a decreased amount of knowledge on the guides, fear of being sued if missing serious pathology, and an effort to appease patients’ desires and, in my opinion, be the “good guy” in the patients’ eyes. However, the authors explain that there are some examples of successful implementation and that widespread use may be achieved through dispelling existing established practice patterns, repetition of the guides, and finding out what is the most effective and cost-effective treatments.
The authors suggest integrated education of health-care professionals surmising that such a thing could not only educate & innovate but also break through professional barriers that exist. Professional barriers such as exist between many in the medical field and the chiropractic field.
Clinical systems and pathways
The authors say that one solution in the treatment of low back pain could be a radical departure from current procedure and move toward a stratified primary care model known as STarT Back. This model is a two-part model with the first part consisting of a questionnaire to help the practitioner identify the patient’s risk of persistent disabling pain. The second part consists of treatments tailored to the patients level of risk according to the first part questionnaire.
Another option along these lines would be to redesign the entire case management paths from first contact all the way through to the specialized care practitioner. They argue that a current barrier to doing this is the fact that healthcare reimbursements are currently geared toward quantity rather than quality. Two programs the authors cited for examples of promising pathways are Canada’s Saskatchewan Spine Pathway as well as NHS England’s program.
Integrate health and occupational interventions
The authors argue in this section that healthcare and occupational health interventions need to be considered simultaneously when it comes to patients with low back pain and work disability issues. Return to work commonly happens before the absence of pain. Even hurting, people can still return to work. The authors tend to have a very strong recommendation on never leaving work or returning as quickly as possible.
Due to very specific examples, I have admittedly glossed over this section to avoid inaccuracies and unintended generalizations. I highly encourage your reading the paper on your own time for accuracy.
Public health interventions
In this section, the authors are discussing public relations: how to get the word out. How to change public perception of back pain and the treatment of low back pain. They cite a successful campaign in Australia that used television ads with prominent public figures serving as the spokespeople. They felt it was well-funded and was successful in part due to the proper messaging but also due to laws and public policies that supported the campaign.
There is a large gap between what evidence suggests and what practitioners are actually doing in their day to day practice in the treatment of low back pain and in the recommendations they commonly make.
- “Focusing on key principles, such as the need to reduce unnecessary health care for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps.”
- “No single solution will be effective, and a collective, global effort will take time, determination, and organization. Without the collaborative efforts of people with low back pain, policy makers, clinicians, and researchers necessary to develop and implement effective solutions, disability rates, and expenditure for low back pain will continue to rise.”
A paper of this size and of this magnitude, and with the level of education of contributors honestly cannot be done complete justice by a review such as this. I admittedly hit the high spots on the treatment of low back pain. I am more focused in some areas than in others. More specific for some topics and more general in others. That is the nature of a summarization and I hope I am allowed that latitude.
If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients and interested in treatment of low back pain, it is my opinion that taking the time to read these three papers yourself is of utmost importance.
Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt.
For this week’s next step, go register with The Lancet and get this paper for free! You just have to register. That’s it.
Next week we will review the third and final paper of this three paper series. Next week’s paper is called “Low back pain: a call to action.” It will continue with ideas toward treatment of low back pain. We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!
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We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
Here is the link for Part One of The Lancet Review from last week:
Paper 1 – “What low back pain is and why we need to pay attention: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext
Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext
Paper 3 – “Low back pain: a call for action”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext