Low Back Pain

What low back pain is and why we need to pay attention

Prof Jan Hartvigsen, PhD*

, 

Mark J Hancock, PhD*

, 

Alice Kongsted, PhD

, 

Prof Quinette Louw, PhD

, 

Manuela L Ferreira, PhD

, 

Stéphane Genevay, MD

, 

Damian Hoy, PhD

, 

Prof Jaro Karppinen, PhD

, 

Glenn Pransky, MD

, 

Prof Joachim Sieper, MD

, 

Prof Rob J Smeets, PhD

, 

Prof Martin Underwood, MDCorrespondence information about the author Prof Martin UnderwoodEmail the author Prof Martin Underwood

 on behalf of the 

 Lancet Low Back Pain Series Working Group†

 

*Joint first authors

†Members listed at the end of the report

Published: 21 March 2018

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DOI: https://doi.org/10.1016/S0140-6736(18)30480-X

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Key messages

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  Low back pain is an extremely common symptom in populations worldwide and occurs in all age groups, from children to the elderly population
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  Low back pain was responsible for 60·1 million disability-adjusted life-years in 2015, an increase of 54% since 1990, with the biggest increase seen in low-income and middle-income countries
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  Disability from low back pain is highest in working age groups worldwide, which is especially concerning in low-income and middle-income countries where informal employment is common and possibilities for job modification are limited
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  Most episodes of low back pain are short-lasting with little or no consequence, but recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences
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  Low back pain is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and pain-processing mechanisms
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  For the vast majority of people with low back pain, it is currently not possible to accurately identify the specific nociceptive source
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  Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes
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  Costs associated with health care and work disability attributed to low back pain vary considerably between countries, and are influenced by social norms, health-care approaches, and legislation
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  The global burden of low back pain is projected to increase even further in coming decades, particularly in low-income and middle-income countries
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• Prevention and treatment of low back pain: evidence, challenges, and promising directions

  Prof Nadine E Foster, DPhilCorrespondence information about the author Prof Nadine E FosterEmail the author Prof Nadine E Foster

  , 

  Prof Johannes R Anema, PhD

  , 

  Dan Cherkin, PhD

  , 

  Prof Roger Chou, PhD

  , 

  Prof Steven P Cohen, MD

  , 

  Prof Douglas P Gross, PhD

  , 

  Paulo H Ferreira, PhD

  , 

  Prof Julie M Fritz, PhD

  , 

  Prof Bart W Koes, PhD

  , 

  Prof Wilco Peul, PhD

  , 

  Prof Judith A Turner, PhD

  , 

  Prof Chris G Maher, PhD

   on behalf of the 

   Lancet Low Back Pain Series Working Group†

   

  †Members listed at the end of the report

  Published: 21 March 2018

  PlumX Metrics

  

  DOI: https://doi.org/10.1016/S0140-6736(18)30489-6

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  Article Info

  • Summary

  • Full Text

  • Tables and Figures
  • References
  • Supplementary Material

  Jump to SectionIntroductionPreventionTreatmentThe global gap between evidence and practicePromising directionsImplementation of best available evidenceClinical systems and pathwaysIntegrate health and occupational interventionsConclusionsSearch strategy and selection criteriaSupplementary MaterialReferences

  Summary

  Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

  This is the second in a Series of two papers about low back pain

  Jump to SectionIntroductionPreventionTreatmentThe global gap between evidence and practicePromising directionsImplementation of best available evidenceClinical systems and pathwaysIntegrate health and occupational interventionsConclusionsSearch strategy and selection criteriaSupplementary MaterialReferences

  Introduction

  Despite the plethora of treatments and health-care resources devoted to low back pain, back-related disability and population burden have increased.1, 2 The first paper3 in this Series describes the global burden and effect of low back pain and provides an overview of the causes and course of low back pain. In this Series paper, we summarise the evidence for effectiveness of interventions for the prevention and treatment of low back pain and the recommendations from best practice guidelines. Despite generally consistent guideline recommendations around the world, clear evidence exists of substantial gaps between evidence and practice that are pervasive in low-income, middle-income, and high-income countries. Different response strategies are needed that prevent and minimise disability and promote participation in physical and social activities. Here we highlight examples of effective, promising, or emerging solutions from around the world and make recommendations to strengthen the evidence base for them.

  Jump to SectionIntroductionPreventionTreatmentThe global gap between evidence and practicePromising directionsImplementation of best available evidenceClinical systems and pathwaysIntegrate health and occupational interventionsConclusionsSearch strategy and selection criteriaSupplementary MaterialReferences

  Prevention

  By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate (table 1). Most of the widely promoted interventions to prevent low back pain (eg, work-place education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices) do not have a firm evidence base. A 2016 systematic review4 identified only 21 trials with 30 850 adults (one in a low-middle-income country [Thailand]), and a 2014 systematic review5 analysed only 11 randomised controlled trials with 2700 children (one in a low-middle-income country [Brazil]). The authors of the review in adults concluded that moderate quality evidence existed that exercise alone, or in combination with education, is effective for prevention; and poor to very-poor quality evidence existed that education alone, back belts, shoe insoles, and ergonomic programmes might not be effective.4 The preventive effect of exercise and education was large, with a pooled relative risk of 0·55 (95% CI 0·41–0·74); however, the trials were mainly of secondary prevention and the effective programmes were quite intensive (eg, 20 1-hour sessions of supervised exercise in one trial).4 The authors of the review in children concluded that moderate quality evidence existed that education is not effective and very low quality evidence existed that ergonomically designed furniture could prevent low back pain compared with conventional furniture.5
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