A couple weeks ago ‘low back pain’ stole the media spotlight due to a series of papers published in the highly respected medical journal, Lancet. The headlines included things like ‘back pain treatment is useless’ and ‘global burden of low back pain the consequence of negligence and misinformation’ and ‘back pain causes more absenteeism than cancer’. Those are some eye popping headlines that got everyone’s attention, including many our patients and community partners. We figured we would let the ‘panic and hysteria’ dust settle before weighing in.

The authors propose that Low Back Pain is a global challenge, due to rising medical costs, increasing disability rates (including absenteeism from work) and expectation for medications, imaging, surgery and other services that are largely unnecessary. We couldn’t agree more. We live in the greatest country in the world, which provides health care for all, but the system can no longer handle the frequent emergency room visits, the demanding requests for advanced imaging, the costly injections and complicated surgeries for back pain. We have a social, economic and policy problem on our hands that demands change. Change in public perception, clinician behaviour, health care system management while addressing conflicts of interests among third parties such as insurers etc.

We won’t pretend we can fix our health care system or government policy or insurers….but we certainly can lead behaviour change among clinicians to make evidence based choices and help shift the public perception.

So what should and shouldn’t you do when you experience low back pain?

Acute Low back Pain:

First off don’t call the ambulance or go to the emergency room. In some countries 20% of all ambulance calls are due to back pain, and 10% of emergency room visits are due to back pain. In one study less than 1% of those ER back pain visits resulted in specific treatment for specific pathology in the back (infection, fracture, tumour etc). More and more we are hearing patients get sent home from emergency rooms with no treatment, testing or imaging at all. This is not a problem with Emergency Room Physicians, it is a problem with an emergency room system that is ill equipped to manage acute back pain. (side note: there are some hopeful trials at several Ontario hospitals to improve ER department care of acute low back pain).

First line therapy should be non-pharmaceutical. Several national guidelines endorse the use of exercise, massage, acupuncture and spinal manipulation (adjustments) in the management of acute (new onset or sudden episode) low back pain. It is not necessary to get x-rays (or other images), prescriptions or referrals for these services from your physician prior to seeing a physiotherapist, chiropractor or massage therapist.

If you feel like you need to medicate, do not use opioids (Oxycontin, Percocets etc.) instead guidelines recommend a non-steroidal anti-inflammatory (NSAID), such as advil or ibuprofen, with the minimal effective dose for shortest amount of time possible. A muscle relaxant could also be considered for a very short period of time.

A very important message from the series of recent Lancet publications is with most cases of low back pain remain active and stay at work. Take a second to absorb that message. This may seem counter-intuitive and in some cases impossible…won’t these make my pain worse??? This requires a complete culture shift. Employers require education and support on HOW to accommodate workers to be able to remain at work. Therapists and other health care workers need training to be able to support patients in HOW to remain active. Health care workers and employers should lead this shift, but if some drag their heels a public that demands to remain active and stay at work will force the full shift.

persistent (lasting longer than 12 weeks) low back pain:

Medications don’t help. Opoids in particular harm. They are the cause of an epidemic of addiction and rising mortality over the past 20 years and are a dramatic example of harmful medical intervention.

Interventional procedures such as injections and surgery have a VERY limited role, are very costly and can add significant complications. Spinal fusions are the most costly surgical procedure performed in the US and they are largely unnecessary.
Machine based physiotherapy treatments such as TENS or ultrasound are a waste of time. Therapists by and large use far too many machines in the name of ‘healing’ or ‘pain relief’. The evidence does not support use of these modalities, especially in persistent low back pain. If you are seeking care in a clinic that relies heavily on using machines for treatment, get out.
Advice should be a cornerstone of treatment. There are many variables that can complicate low back pain, such as workplace stress, family dynamics, occupation demands, general health habits and the list goes on and on. A good practitioner will give advice to help you navigate through these variables helping you make positive healthy decisions to support your recovery. A progressive exercise

Exercise is key. A progressive exercise approach that focuses on functional improvements is critical. The guidelines recommend exercise programmes that take individual needs, preference and capabilities into account to decide the type of exercise program. We couldn’t agree more. An individualized exercise approach NOT a cookie cutter approach is the most effective way to both manage back pain and prevent future episodes. This is more than just hopping on a cardio machine. Or just doing a couple generic stretches for your low back. A progressive program will evolve over time and address weaknesses and limitations to improve the overall health of your back.

We have been beating the individualized exercise program drum for almost 10 years in Burlington. It is the primary reason our clinic will always be associated with a gym.

Please pass this information on to anyone you know who is struggling with low back pain and may be stuck in a cycle of relying on medications, machines, injections and other forms ongoing intensive passive care.