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Low back pain: pause and consider to enact change

Back pain is, quite frankly, a pain in the back…both for the people who have it and the community at large1. Despite its pervasive nature, care for those with back pain continues to diverge from best practice1,2.

The fact that back pain care often diverges from best practice is something we’ve known for decades. But, as we know all too well, change is hard. We’re fighting against institutional issues, patient expectations, and our own ingrained habits3.

It’s going to take a ‘whole-of-community’ approach2 with a focus on education to change back pain outcomes. The good news is, Lifestyle Medicine is well-positioned to lead the charge.

A call to action

In 2018, The Lancet published a call to action with their ‘Low Back Pain Series’,1,4,5 outlining ways to address the increasing and costly effects of low back pain. Many action points were difficult to address as individual practitioners, however, two points stand out:

  1. “Patients should be taught to self-manage low back pain and seek care only when really needed”3
  2. “Widespread and inaccurate beliefs about low back pain …should be challenged, and a focus put on reducing the impact of low back pain … rather than seeking medical treatment for a ‘cure’”3

Both of these actions require practitioners to place education as central to their care approach 2. In fact, education is already universally recommended as first-line treatment for acute and persistent back pain2,6,7, but is consistently under-utilised for reasons including lack of time, lack of skills or lack of content knowledge2.

Why is education so important?

How pain is processed, experienced, and understood plays a central role in the development and maintenance of pain3. Exposure to a more biomedical interpretation of low back pain has been shown to increase disability by shifting the belief that back pain is an uncomfortable yet normal part of everyday life, towards the idea that back pain is a medical condition that requires attention and treatment3.

To implement the Lancet’s1 call to action in practice, we could start by re-framing our role in treating back pain. Once we have ruled out red flags, we can think of ourselves as coaches who can support our patients to address any counter-productive beliefs they hold, promote self-efficacy, and develop a deeper understanding of the nature of pain2.

Below are four simple ‘pause and think’ moments we could use to align our practice with the best evidence and support our patients to navigate back pain with less distress.  

(1) Pause and consider: imaging – considerations and education

Spinal imaging is useful and sometimes necessary, but has been shown to have adverse consequences on individual patient outcomes when used incorrectly8. The biggest issues are that imaging is often overused, relevance of incidental findings such as age-related changes are often misinterpreted, and the relevant findings are poorly communicated8. Overuse of imaging can lead patients to believe their spine is damaged8, which can lead to unhelpful beliefs about their back health that are connected to increased distress and enhanced pain8.

There are numerous reasons why imaging is used when it may not be appropriate, but the key reasons often lie with clinician and patient expectations. In Australia, the majority of people expect imaging because they believe it will identify a cause for their pain and is therefore necessary for effective care6. Education on the divergence between pain and imaging could assist in changing this expectation8.

Before we image, it’s important to pause and ask ourselves, “Have we listened to our patient’s story”, or are we concerned about litigation and patient expectations8? Have we considered the potential negative psycho-behavioural consequences for our patient if incidental findings are found? And have we discussed the role imaging with our patient?

If we do decide imaging is appropriate, then it is important we take a minute to explain the findings to our patients8 and:

  • contextualise the radiological findings within age-related norms
  • use reassuring and non-threatening language to discuss results
  • educate our patients on the non-pathoanatomical contributors to pain

(2) Pause and consider: educate, then medicate (where appropriate)

Medication is the most common treatment provided to people with low back pain in Australia7. Yet the research into back pain makes it increasingly clear that medication alone is inadequate, and in some cases harmful3. So, what do we do?

If we are going to medicate, we can ensure we do it alongside appropriate education. All first-line care should include advice for patients to keep moving where possible, reassurance about the high chance of the back pain improving, and the low chance of serious disease6. Additionally, it’s useful to let your patients know recurrence is common and does not equate to a more serious injury6.

Many guidelines suggest that other non-pharmacologic treatment may be considered6 for acute low back pain such as application of heat to the area and/or referral to a physical therapist (physiotherapist/osteopath/chiropractor/acupuncturist/massage therapist).

Where pain is persistent, referral to physical therapists with a background in pain education may be best2. Referral to a psychologist may also be considered for persistent low back pain for cognitive behavioural therapy, mindfulness-based stress reduction, and/or other psychological support6.

If medication is appropriate, we should ensure our patients know how to use it correctly. Short NSAID courses have been shown to be useful for both acute and persistent cases on NSLBP, but should be used as second-line therapy6.

Muscle relaxants have also been found to be helpful for pain relief in acute low back pain, but their use should be weighed against possible harms such as increased risk of dizziness, drowsiness or sedation6.

While various guidelines differ on the use of opioids for acute low back pain6 where NSAIDS are not tolerated, all guidelines recommend not using opioids for persistent low back pain3,7.

(3) Pause and consider: tell our patients what the research says they value learning about pain

Knowledge is powerful, particularly where pain is concerned. Explaining the neuroscience of pain has been shown to reduce pain, improve movement and reduce fear avoidance2,7.

Research9 tells us that people with persisting pain value being taught three key ideas:

  1. An increase in pain does not equal an increase in damage9. Pain is a protective feeling, so we need to reassure our patients that not finding a cause for their pain is a great thing. This is particularly true for low back pain where in the vast majority no particular cause will be found3.
  2. Thoughts, emotions and experiences can affect pain9. This is our opportunity as Lifestyle Medicine practitioners to say, “Let’s find out what else has been going on in your life?” and ask the deeper questions about sleep, stress, diet etc.
  3. Lastly, people value learning that the pain system can be overprotective, but that this can be changed over time9. We are bioplastic beings, meaning that we’re always learning. Patients understand and value knowing that bioplasticity can make your pain system overprotective, but it also means that your nervous system can improve over time9.

(4) Pause and consider: taking a ‘whole-of-community’ approach means using our community

Use the people within the healthcare system who are already skilled in delivering pain education. If you do not feel that you have the skills or time to address unhelpful beliefs or provide self-management support but can see a patient would benefit from these things, use your wider community. Part of the power of Lifestyle Medicine is that we have such a wide array of skills captured under one umbrella in the healthcare workforce. We believe an interdisciplinary approach is best, and this is no different in the way we care for those with back pain.

For example, a growing number of physical therapists have completed additional training in pain education delivery2. Some psychologists are also skilled in pain science delivery, and they have the billing codes to support education delivery2.

As a whole community, we can work together to tackle this problem. Sometimes, the best thing we can do after and while looking after our patient is take a moment to explain the relevance of findings from an x-ray or reassure your patient that pain is unpleasant, but their back is strong and the pain will resolve over time. Small changes can have a ripple effect through the community.

Summing up

Change is difficult, but the rewards are great. It’s going to take working as a whole community to facilitate long-term, meaningful change that provides education as central to care. We will need to support each other and focus on consistent messaging across a wide array of healthcare practitioners. Enacting such an approach makes Lifestyle Medicine practitioners well-positioned, arguably uniquely well-positioned, to take the lead.

  1. Buchbinder R, van Tulder, Maurits., Öberg, Birgitta., Menezes Costa, Lucíola ., Woolf, Anthony., Schoene, Mark., Croft, Peter,. . Low back pain: a call for action. The Lancet 2018;391(10137):2384-88.
  2. Moseley GL. Whole of community pain education for back pain. Why does first-line care get almost no attention and what exactly are we waiting for? Br J Sports Med 2019;53(10):588-89. doi: 10.1136/bjsports-2018-099567
  3. Buchbinder R, Underwood M, Hartvigsen J, et al. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain 2020;161(9):S57-S64. doi: 10.1097/j.pain.0000000000001869
  4. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet2018;391(10137):2356-67. doi: 10.1016/S0140-6736(18)30480-X
  5. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391(10137):2368-83. doi: 10.1016/S0140-6736(18)30489-6
  6. Traeger A, Buchbinder R, Harris I, et al. Diagnosis and management of low-back pain in primary care. CMAJ2017;189(45):E1386-E95. doi: 10.1503/cmaj.170527
  7. Bagg M. Towards improved treatment for people with chronic low back pain. University of New South Wales. Prince of Wales Clinical School, 2021.
  8. Wheeler LP, Karran EL, Harvie DS. Low back pain: Can we mitigate the inadvertent psycho-behavioural harms of spinal imaging? Australian journal of general practice 2018;47(9):610-13. doi: 10.3316/informit.849749411800012
  9. Leake HB, Moseley GL, Stanton TR, et al. What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education. Pain 2021;162(10):2558-68. doi: 10.1097/j.pain.0000000000002244

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.

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