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Contemporary low back pain research – and implications for practice

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Each month, several journals contain reports on new ways of looking at low back pain-related risk and prognostic factors, new clinical interventions and suggestions for improved care. This is because back pain continues to be a vexing condition to manage. It often defies evaluation, diagnosis and treatment, and is associated with considerable individual suffering and negative societal impact. Although reviewing new and promising strategies is always interesting and gratifying for the reader, it is sobering to reconsider similar efforts over the past decades. Most new ideas for low back pain care have not proven to be effective when subjected to repeated rigorous and independent evaluation. New developments in epidemiologic and clinical understanding, and innovative approaches to non-medical management now appear to provide the best opportunities for improving outcomes. In this article, we review new perspectives and research studies that show promise, and suggest alternatives to current clinical and research paradigms.

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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