Low Back Pain is Not a Disease - What is The World’s Most Disabling Condition?

Recently, 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 12page, 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?
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. 
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 L4, L5 multifidi.6-8 The multifidi alone provide 2/3 of spinal stability in the L4-L5 proximity,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 current study. 
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 evidence we have points to physiotherapy as the first-line treatment. Patients managed passively have a 180% greater 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 costeffective at improving quality of life and  curbing other healthcare spending such as imaging, injections, and oral analgesics. Immediate referral 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 your patients.

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 8. Hides J, Richardson C, Gwendolen J. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996; 21 (23): 2763-2769. 9. Wilke H, Wolf S, Claes L, et al. Stability increase of the lumbar spine with different muscle groups: A biomechanical in vitro study. Spine .1995; 20: 192-8. 10. Rantanen J, Hurme M, Falck B, et al. The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine. 1993: 18: 568-74. 11. Rundell S, Sherman K, Heagerty P, et al. The clinical course of pain and function in older adults withy a new primary care visit for back pain. J Am Geriatr Soc. 2015; 63: 524-30. 12. Itz CJ, Geurts JW, Van Kleef M, Nelemans P. Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain. 2013 Jan;17(1):5-15.  13. Australian Institute of Health and Welfare 2016. Impacts of chronic back problems. Bulletin 137. Cat. no. AUS 204. Canberra: AIHW.  14. Ammar T. A randomized comparison of supervised clinical exercise versus a home exercise program in patients with chronic low back pain. Physical Therapy and Rehabilitation. 2017 Aug; 4( 1): 7.  15. Ford J, Hahne A, Surkitt L, et al. Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. Br J Sports Med. 2016; 50: 237-245. 16. Oliveira V, Ferreira P, Maher C, et al. Effectiveness of self-management of low back pain: systematic review with meta-analysis. Arthritis Care & Research. 2012; 64 (11): 1739-1748. 17. Campian M, Hedin T, Hansen P, et al. Rapid access to physical therapy for low back pain: a continuous quality improvement project. Presented at: Annual Meeting of the Association of Academic Physiatrists. 2017; Sacramento, CA, USA. 18. Fritz J, Childs J, Wainner R, Flynn T. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.  Spine. 2012; 37 (25): 2114-21. 19. Sihvonen T, Herno A Palijarvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine. 1993; 18: 575-578. 20. Workin LL, Smeets R. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 Jun 9;391(10137):2368-83.  21. Keating JL, McKenzie JE, O'Connor DA, French S, Walker BF, Charity M, Page MJ, Green SE. Providing services for acute low-back pain: A survey of Australian physiotherapists. Manual Therapy. 2016 Apr 1;22:145-52. 



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