Low back pain is more than just a nuisance for the people suffering from it, it’s a nuisance for the health care system and economy at large.  It’s one of the most common ailments people seek health care for, and to boot, many of these people continue to get the wrong care costing taxpayers (in Canada at least) in a big way.  This is hard to reconcile.  We have a global rising disability epidemic of low back pain and seemingly a system that continues to lead people down the wrong pathway.  What gives? 

2 years ago there was a landmark series published in the Lancet aimed to get the facts straight on the best guidelines for low back pain care.  The 3 part series in combination with a well crafted public release generated an unprecedented amount of media coverage.

 

We reviewed the landmark series in an article  shortly after it was published.

 

This same author group recently provided an updated report with some additional considerations and an renewed urgency to continue the conversation.

 

To summarize low value care treatment for low back pain includes visits to the ER, liberal use of diagnostic imaging (including MRI’s), opioids, spinal injections and surgery.

 

As an update to the cost of excessive diagnostic imaging a 2019 systematic review of 14 studies found that imaging is associated with increased health care utilization, more work absence and higher medical costs compared to non-imaged groups.

 

We’ve noticed more and more patients now recognizing the pitfalls of starting with the imaging goose chase, so the message is getting out.  However the system at large across the world still has not budged in the last couple years.  

 

This is the vicious cycle the lancet article authors acknowledge:

 

“Patients request imaging expecting a diagnosis, clinicians order imaging because of entrenched beliefs and habits, perceived pressure from patients, fear of litigations and financial incentives; and health care systems continue to offer liberal access to imaging probably because of public demand and pressure from clinicians.”   

 

This issue simply isn’t going away anytime soon.   

 

Although the rates of opioid prescriptions are falling in high income countries such as Canada, UK and US, prescriptions have now shifted to Gabapentin.  Experts argue that Gabapentin is not addictive and therefore does not pose the same downside of opioids.  Gabapentin is often referred to as a  “nerve drug” and in Canada is commonly employed in cases of suspected nerve pain such as sciatica.  But the evidence simply does not support the use of Gabapentin for low back pain or sciatica.  Let’s hope the medical system will not just shift to a new drug and continue to repeat the mistakes of the last decade. 

 

Enough of what not to do…what should you do when confronted with back pain.  Recommended standard first line care has not changed since the 2018 Lancet series and includes advice to stay active, avoid bed rest, option of spinal manipulation and/or simple analgesics.

 

Exercise is still king.  Group based in-person and online exercise interventions (SOLAS project in Ireland) and a more one size fits all approach for exercise and advice (GLA:D in Denmark) are currently being tested for efficacy.  While cost effective, and intriguing in their ability to “scale”…it is simply too early to broadly promote any of these programs.  We will continue to monitor these research initiatives with interest.

 

The best approach has always been, in our opinion, one that combines a progressive, individually tailored exercise program (with or without manual therapy such as manipulation) that accounts for individual needs, preferences and capabilities.  This is why we set up our clinic alongside a gym 12 years ago.  The gym provides the opportunity, but it’s not the secret sauce.  It’s the clinicians who know how to effectively use those gym resources to optimize results for their patients.  12 years in and thousands of low back pain patients later, as a group, we are committed to mastering the art and science of exercise as the cornerstone for treatment of your low back pain.