Low back pain: A major global challenge

Lower back pain is the leading cause of years lived with disability worldwide and in the UK. In order to highlight this condition, the Lancet has recently published a review series on low back pain: a major global challenge, including the three following papers:

  • What low back pain is and why we need to pay attention.
  • Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  • Low back pain: a call for action.

Some of our funded researchers, including from the Arthritis Research UK Primary Care Centre have been involved in this work.

Here we speak to one of the lead authors in the series, NIHR Professor Nadine Foster to try and understand what this means for health care professionals and what they can do to make a change.

Key messages from the series

The first paper in the series ‘What low back pain is and why we need to pay attention’ looks at what low back pain is and highlights the prevalence of the condition. Low back pain is now the number one cause of disability globally and is still increasing despite efforts to make a change. With an ageing population it’s almost inevitable that a person will get low back pain.

The second paper in the series ‘Prevention and treatment of low back pain: evidence, challenges, and promising directions’ draws attention to the mismatch between the guidelines and the care that is given, globally. It highlights that for most people back pain is a symptom and not a disease, so a purely biomedical model is not appropriate.

Current care all around the world relies too heavily on pharmacological therapy, interventional therapies and surgery instead of the treatments with the strongest evidence base. The emphasis needs to be on function and living a full life despite back pain, supported by the most effective non-pharmacological treatments.

This paper considers how to implement best practice and how this can be made easier for clinicians. The paper highlights examples of effective, promising, or emerging solutions, by solution target.

The third paper in the series ‘Low back pain: a call to action’ summarises the health care challenges associated with low back pain and identifies actions to meet them. It suggests using the notion of positive health in the management of non-specific low back pain, the ability to adapt and to self-manage in the face of social, physical and emotional challenges.

It addresses widespread misconceptions in the population and among health care professionals about the causes, prognosis, and effectiveness of different treatments for low back pain. It also highlights the key challenges for policy, public health and health care. Action is urgently needed as doing more of the same isn’t going to reverse the increasing global disability due to low back pain.

What can health care professionals do?

Health care professionals need to give the right evidence-based care early on. Focusing on key principles, such as the need to support people with back pain to be active and stay at work, and to reform unhelpful patient clinical pathways and health care reimbursement models can guide next steps.

What can you do:

  • Consider the overview of interventions endorsed for non-specific low back pain in evidence based clinical practice guidelines (Paper 2, table 2). This highlights recommendations for acute low back pain and persistent low back pain and the differences between these.
  • Read ‘The National Low Back Pain and Radicular Pain Pathway’ (PDF 2.5MB). This UK pathway is now being implemented nationally – see if you can get engaged with this in your area.
  • Reflect on the challenges highlighted in the third paper and think about where you can make a difference.

STarT Back as an example of a good clinical pathway

Stratified primary care for low back pain based on prognosis (STarT Back) is an example of a new way of delivering health care. Current UK (NICE) clinical guidance now recommends risk stratification. The Keele STarT Back tool identifies patients at low risk of persistent disabling pain who can be supported to self-manage, whilst also identifying patients who are at medium or high risk for whom further health care is needed, such as a course of physiotherapy. The tool helps us to identify patients with different prognoses and to use this information systematically in making decisions about health care. Stratified care based on using the STarT Back tool and then matching patients to different treatments has been developed and tested in the UK primary care setting, and has been shown to bring benefits for patients and for the NHS (it is cost effective).

The STarT Back tool is used by a range of clinicians such as GPs, physiotherapists, osteopaths, and chiropractors. You can find out further details about the tool and matched treatments here.

What next?

The series is written from the point of view of the desire to want things to change. A policy briefing is currently being produced summarising all the key actions. The question is who will take an interest in ensuring things change? There needs to be a collaborative effort between policy makers, clinicians, researchers and research funders to develop, test and implement effective solutions or disability rates and expenditure for low back pain will continue to rise.