12Contemporary low back pain research – and implications for practice
Section snippets
The cause and course of low back pain
Many people with low back pain do not present for medical care and it is important to differentiate between studies that have attempted to identify risk factors for the development of back pain per se from studies that have investigated factors that predispose individuals to present for care. While there is still controversy about the cause(s) of non-specific low back pain, the contribution of especially heavy work to an increased incidence of clinical care for low back pain has been reinforced
Early intervention for low back pain – educational approaches
Almost all episodes of acute low back pain appear to follow a course that is not altered much by traditional medical treatments. Longitudinal, population-based studies suggest that the outcomes are similar in comparable persons who seek care versus those who do not [9]. This implies that most clinical interactions at best provide reassurance, and often lead to a process that is wasteful, and may be iatrogenic – creating a negative psychological mindset, or perhaps even leading to worse injury
Acute low back pain evaluation and treatment
There are no traditional clinical approaches to acute low back pain that have large, statistically significant and consistent benefits over placebo, in rigorous trials [29], [30]. It has been postulated that, within large groups who have minimal benefits from a specific treatment, there are a few who have significant responses, leading to calls for recognition of important distinguishing characteristics, or risk subgroups, within the umbrella of ‘nonspecific low back pain’. Yet, so far there
Sub-acute and chronic low back pain
Relatively few low back pain sufferers have chronic and severe pain, but this group accounts for the majority of morbidity, adverse impact on quality of life and associated costs from low back pain. Thus, most research is directed towards these challenging cases – unfortunately, without much success in achieving a breakthrough. As of late October 2009, over 60 new clinical trials on low back pain had been recorded in the World Health Organization (WHO) Clinical Trials Registry; all but eight
Surgical candidates
As discussed by Rosenberg et al. in this issue, surgery for sciatica leads to faster recovery for persistent radicular pain after 6 weeks, although similar outcomes are observed over the long term. For back pain with non-radicular symptoms, intensive non-operative treatment may lead to similar or perhaps better outcomes than operative treatment [54]. Tumour necrosis factor inhibitors have been touted as a possible breakthrough for the treatment of sciatica without surgery, although initial
Knowledge translation
Some leaders in the field have now taken the view that more effective application, implementation and public policy aligned with current knowledge, rather than new clinical innovations, is what is most needed [57]. Over a decade ago, several studies demonstrated that providing patients with timely and accessible information about their treatment could increase the quality of their decision making, and perhaps enhance their self-management. The efforts at community-wide and workplace-based
Conclusion
There have been some important areas of progress over the past 5 years. Promising and evolving ideas include the paradigm shift to consider back pain course more broadly and studying trajectories of recovery, increased focus on prognostic factors and early prognostic screening, methods of subgroup identification, cognitive behavioural approaches and early return to work/disability prevention interventions. A continuing challenge is to get this scientific evidence into routine clinical practice.
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Cited by (36)
Decision support tools in low back pain
2016, Best Practice and Research: Clinical RheumatologyCitation Excerpt :However, this is an umbrella term that lacks diagnostic clarity, resulting in a heterogeneous population. It has been argued that treatments are not specifically tailored to the relevant subgroups of patients but that, instead, many treatments use a (more or less) one-size fits all approach [7]. To achieve more substantial results of treatment and/or a reduction of health care utilization, matching groups of patients with the most appropriate treatment for their profile, referred to as stratified care, has been advocated [8] and is (for many years already) one of the top research priorities in the field of low back pain [9].
Back pain: Prevention and management in the workplace
2015, Best Practice and Research: Clinical RheumatologyClinical challenges of classification based targeted therapies for non-specific low back pain: What do physiotherapy practitioners and managers think?
2015, Manual TherapyCitation Excerpt :Each year 6–9% of adults consult their GPs about back pain (Dunn and Croft, 2006; Jordan et al., 2010) which in the majority of cases is non-specific (NSLBP) (Waddell, 2004). Most available treatments have low to moderate short lasting benefits (Pransky et al., 2010; Patel et al., 2013), suggested to result from the NSLBP heterogeneity and variable treatment response (O'Sullivan, 2006). Identification of subgroups to better target care and maximize treatment potential is a pressing research priority (Costa et al., 2013) and was a key research recommendation in a recent National Institute of Clinical Excellence (NICE) Guideline for Early Management of Persistent Non-Specific Low Back Pain (Savigny et al., 2009).
Medical management of chronic low back pain: Efficacy and outcomes
2014, NeuromodulationCitation Excerpt :As a consequence, the syndromes of up to 85% of patients with LBP evaluated in primary care settings are designated nonspecific (7–9). This characterization reflects two well-studied facts: Most patients with acute presentations recover to a near baseline level of functioning within six weeks of episode onset and, frequently, the interpreted findings of neuroimaging studies (e.g., annular tear and vertebral endplate changes) lack sensitivity and specificity for the experience of acute or chronic LBP (10,12). A systematic review of literature that examined the course of acute LBP found that on measures of pain and disability, patients improved rapidly within the first month, sustained more modest improvements after three months, then began to demonstrate reduced improvement or none at all (13).