Low back pain costs us; it costs Australia upwards of $1.2 billion per year and it costs our patients in time off work and overall quality of life1. It’s a big problem and the budget blow-outs and ever-increasing burden of disease associated with low back pain shows that we’re not handling it well2.
Best practice models around the world are calling for a decrease in pharmacotherapy and imaging and the use of an inter-disciplinary approach to care. Yet, disappointingly, the data shows that we’re largely ignoring this advice2. To address the issues surrounding the gap between current practice and best practice we need a culture change in the way we address low back pain3. Lifestyle Medicine is well suited to lead the charge.
Treating low back pain: The current situation
We currently use a fragmented biomedical model of care with a focus on diagnosis of injury to the back and medication as first line management4. One of the biggest issues is that we don’t have clear pathways for addressing low back pain and the messages around back pain are often inconsistent. This is something that we, as Lifestyle Medicine practitioners, can work together to change. This article will attempt to address some of these issues and show that we all have a part to play.
Culture Change One: Mechanisms and causes
The model that we use to think about the mechanisms and causes of low back pain plays a large role in the way we approach treatment and can significantly alter the quality of care that we provide.
Current Model: The search for the elusive pain causing structure. The Biomedical model of care is founded on the notion that there is a direct, causal relationship between an illness and its signs and symptoms5. It’s a useful way of understanding certain diseases, but problematic in low back pain, where the majority of pain is ‘non-specific’.
A small proportion of cases of persistent low back pain require a specific diagnosis (such as malignancy, vertebral fracture, infection, or inflammatory disorders such as axial spondylarthritis)4. These require a biomedical model of thinking. However, most low back pain cannot be attributed to a single musculoskeletal structure. MRI may show abnormalities in certain discs, joints, ligaments or muscles, but in the majority of cases these findings are similar to the MRIs of people with no back pain4. For this reason, best practice guidelines state that routine use of laboratory tests and imaging should be avoided unless they are likely to change the treatment pathway, such as with a suspected infection6.
Culture Change Model: The patient as the centre of the puzzle: The way we think about diagnosis in low back pain has to change. Once we’ve ruled out any conditions that require a specific diagnosis we need to take off our biomedical model hats, and stop searching for a cause of pain. Our responsibility as practitioners shifts as we focus on how to best reassure, educate and assist our patients to self-manage their low back pain. A task well suited to the Lifestyle Medicine model.
Culture Change Two: Developing our knowledge of prognosis and natural history of low back pain
It is difficult to summarise everything we know about low back pain in a couple of paragraphs, but what we do know supports a model of care that focusses on reassurance, pain education and advice to keep moving.
Low back pain is often a long-lasting condition. Some people recover fully, but many have fluctuating episodes of pain ranging from low to moderate intensity. Most people will experience a significant decrease in pain within six weeks, but up to a third will report a recurrence of pain within a year of the previous episode4.
People at higher risk of recurrence are those who have had a previous episode of back pain, and people with other chronic conditions such as asthma, headache and diabetes, as well as people with poor mental health. Awkward postures, heavy manual tasks, feeling tired or being distracted during an activity are all associated with an increase in a developing a new episode of low back pain6.
It is interesting to note is that there is little correlation between MRI findings and the ability to predict the course of low back pain or the likelihood of future episodes4. There is also poor evidence to support certain preventative strategies such as back belts, no lift policies or the use of firm mattresses6. Active approaches, such as exercises are associated with reduced long term disability, whereas rest and reliance on medication are associated with poorer long-term outcomes4.
The biggest impact on long term outcomes has been shown to be a combination of education and exercise6. The downside is that currently the most successful programmes are intensive (20 hours or more). The success of these programmes compared to general care across the health system may lie in the fact that the messages are so mixed across the rest of the healthcare system. Lifestyle medicine could change this.
Lifestyle Medicine could provide the opportunity to work together to provide consistent messaging that is aligned with the best evidence available across referral partners. Lifestyle Medicine is uniquely suited to change the culture surrounding how we think about and treat low back pain.
Culture Change Three: Working Together to conquer low back pain
Lifestyle Medicine practitioners already have all the tools to use an evidence-based best practice model for low back pain. Through the use of lifestyle prescriptions, consistent messaging and referral to appropriate allied health practitioners we can create our own informal community programmes for low back pain.
A community back pain team may involve a GP and an allied health practitioner, such as an Osteopath, Physiotherapist, Chiropractor or Exercise Physiologist. A practice nurse may be needed to co-ordinate care and other practitioners such as community pharmacists may play a supporting role in education on appropriate medication use, pain and activity.
The key messages across all professions should be:
- Reassurance that back pain is not a serious disease and that symptoms will improve over time. Seventy to 90% of people will suffer from back pain at least once in their lives.
- Keep active. You may want to advise simple exercises such as bringing the knees to the chest and rocking side to side or walks around the block. A short-term modification of activities may be helpful, but remind your patients that full bed rest is not recommended.
- Pain education is important to reinforce the idea that the amount of pain does not equate to an increased level of tissue damage. Many people fear that they will never get better and that any ‘wrong move’ will result in further ‘damage’. If you don’t feel confident discussing pain mechanisms, find someone in your network who is. Moseley (2003) showed that many practitioners under-estimate their patient’s ability to understand pain science. We also under-estimate how powerful pain knowledge can be in improving quality of life when living with pain.
Pain education is an area where allied health practitioners could play a much larger role in the management of low back pain. This group of practitioners often spend more time with their patients, giving them a unique opportunity to explain pain and educate their patients on how to help themselves.
A word on Medication: Pharmacotherapy is not recommended as a first-line intervention6,8, which makes a lifestyle prescription perfectly suited to changing the culture of low back pain. Heat and gentle back exercises could be prescribed instead. If medication is needed, guidelines recommend NSAIDs where appropriate risks have been considered. Opioids are to be avoided except with selected and monitored patients6.
A word on Manual therapy: the role of manual therapy can often be dismissed, as we move more toward active therapies, however, it still has its place8,9. Hands-on therapy may be considered for short-term pain management as hands-on therapy has been shown to modulate pain inputs and assist in return to normal activities. It is useful if the practitioner delivering the therapy has knowledge of pain science.
As Lifestyle Medicine practitioners, we have a unique opportunity to change the culture around low back. We can only do this if we use evidence informed care founded not on searching for a pain causing structure, but on working with our patients to educate and empower them with the knowledge, skills and tools they need to manage their back pain as self-sufficiently as possible. We can work together to change the culture around low back pain.
- Australian Institute of Health and Welfare. Back Problems Snapshot. Australian Government. 24 July, 2018.https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/what-are-back-problems
- Deloitte Access Economics. The cost of pain in Australia. Report for Pain Australia. 4 April, 2019
- Buchbinder, Rachelle, van Tulder, Maurits., Öberg, Birgitta., Menezes Costa, Lucíola ., Woolf, Anthony., Schoene, Mark., Croft, Peter,. (2018) Low back pain: a call for action, The Lancet , Volume 391 , Issue 10137 , 2384 – 2388
- Hartvigsen, Jan., Hancock, Mark J., Kongsted, Alice., Louw, Quinette., Ferreira, Manuela L., Genevay, Stéphane., Hoy, Damian., Karppinen, Jaro., Pransky, Glenn., Sieper, Joachim., Smeets, Rob J., Underwood, Martin., (2018) What low back pain is and why we need to pay attention, The Lancet , Volume 391 , Issue 10137 , 2356 – 2367
- Grimmer-Somers, K., Kumar, S., Milanese, S., Moreton, M and Young, A. (2009). Evaluating best practice purchasing strategies for physiotherapy services for injury-related conditions. Centre for Allied Health Evidence, University of South Australia.
- Foster, Nadine E ., Anema, Johannes R., Cherkin, Dan., Chou, Roger., Cohen, Steven P., Gross, Douglas P ., Ferreira, Paulo H., Fritz, Julie M., Koes, Bart W., Peul, Wilco., Turner, Judith A., Maher, Chris G., (2018) Prevention and treatment of low back pain: evidence, challenges, and promising directions, The Lancet, Volume 391, Issue 10137, 2368-2383
- Moseley, L. (2003). Unravelling the barriers to reconceptualization of the problem of chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology.The Journal of Pain, Volume 4, Issue 4, 184-189.
- National Institute of Health and Care Excellence (NICE) Guideines. (2016). Low back pain and sciatica in over 16s: Assessment and management (NG59).Retrieved from https://www.nice.org.uk/guidance/ng59
- Moseley, Lorimer G., Butler, David S. (2017). Explain Pain Supercharged: The clinician’s manual. Noigroup Publications, Adelaide, South Australia.
This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.