Many Patients Receive Inappropriate Tests, Treatments for Low Back Pain

The overuse of inappropriate tests and treatments for patients with low back pain is discussed in a Series of papers published in The Lancet.

Low back pain is thought to affect roughly 540 million people worldwide and is the leading cause of disability in nearly all high-income countries. But research shows that in reality, this condition is not being treated according to best practice treatment guidelines. 

Although low back pain should be managed in a primary care setting, many patients are being treated in emergency departments. Also, instead of patients receiving education and advice to stay active at work (first-line treatment), patients are being encouraged to stop work and rest, and are being referred for scans or surgery. In addition, they are being prescribed pain medications such as opioids, which are not recommended for the routine treatment of low back pain. 

Upon analyzing evidence from low- and high-income countries, the authors of the Series found that many of the incorrect practices of high-income countries are also being implemented in low- and middle-income countries. For example, rest is commonly recommended in low- and middle-income countries where there are insufficient resources for workplace intervention; in India, bed rest is commonly recommended. 

Opioids were found to be prescribed in about 60% of emergency department visits in the U.S. for low back pain, according to a 2009 study. Exercise, however, was only recommended in about half of U.S. patients with chronic low back pain. In South Africa, 90% of patients were prescribed pain relievers as their only form of treatment. Series author, Professor Nadine Foster, Keele University, U.K., stated, “In many countries, painkillers that have limited positive effect are routinely prescribed for low back pain, with very little emphasis on interventions that are evidence based such as exercises. As lower-income countries respond to this rapidly rising cause of disability, it is critical that they avoid the waste that these misguided practices entail.” 

One of the papers in the Series, “Prevention and treatment of low back pain: evidence, challenges, and promising directions”, includes promising and emerging solutions that address health care and public health, and summarizes the main guideline recommendations in the management of low back pain:

• Low back pain should be managed in primary care
• Provide education and advice
• Remain active and stay at work
• Imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain
• First choice of therapy should be non-pharmacological
• Most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction)
• Due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged 
• Interventional procedures and surgery have a very limited role, if any, in the management of low back pain
• Exercise is recommended for chronic low back pain
• A biopsychosocial framework should guide management of low back pain

With the growing gap between clinical evidence and practice, the authors of the Series emphasize the need for collaborative and effective solutions. “Focusing on key principles, such as the need to reduce unnecessary health care for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps,” they concluded.

For more information visit thelancet.com.