‘Active approach’ aims to break the cycle of lower back pain

Imaging tests, bed rest, pain medicines and surgery have a limited role in managing most people with low back pain, according to newly released clinical care standards.
 
The Low Back Pain Clinical Care Standard, published by the Australian Commission on Safety and Quality in Health Care (the Commission), are the first of their kind to have been released in Australia.
 
Led by Associate Professor Liz Marles, a GP and Clinical Director at the Commission, the standard advocates for a shift towards active approaches to support the one in six Australians with low back pain.
 
‘Contrary to past schools of thought, for most cases of low back pain, we know that passive approaches such as bed rest and medication can lead to worsening disability,’ she said.
 
‘The [standard] describes how active self-managed strategies that educate people about their pain and how to remain physically active and working are most effective to restore health.
 
‘Also, if pain medicines are prescribed, they should be used to enable physical activities to help people recover, rather than eliminate pain.’
 
According to the Standard, current evidence shows an active approach is more effective and less risky for patients with low back pain, which costs the Australian health system $4.8 billion each year, and is the top reason for lost work productivity and early retirement.
 
To combat the issue, it aims to provide practitioners with a ‘road map’ to help patients manage low back pain episodes early and reduce their chance of ongoing problems.
 
Recommendations include self-management and physical activity, addressing psychological barriers to recovery such as thoughts and emotions about pain, as well as tackling social obstacles, including work and home stress.
 
For Associate Professor Marles, the standard marks a leap forward in effective care for low back pain patients, who may be treated across different healthcare disciplines and often receive conflicting advice.
 
She says while a thorough initial assessment screening for serious underlying causes, such as cancer, infections or nerve compression is vital for any new episode of low back pain, the risk of a serious cause is very low (1–5%) and usually identified through history and physical examination.
 
And, paradoxically, the Standards indicate that other investigations can actually delay recovery.
 
‘We have a societal problem around the fundamental beliefs about back pain,’ Peter O’Sullivan, a Professor of Musculoskeletal Physiotherapy at Curtin University, said.
 
‘There are many cases of fear-induced over-treatment of patients, which can make their condition worse. As practitioners, we need to understand what is going on with each patient and help them with a specific recovery plan.
 
‘The evidence shows, and the standard reaffirms, that regular and graduated movement and activity are central to a better outcome for many people with an acute low back pain episode.’
 
Like Associate Professor Marles, he believes there is a need for a consistent approach to back pain across medical professions.
 
‘Unfortunately, sometimes the advice given to people with low back pain can reinforce unhelpful beliefs and responses to pain,’ Professor O’Sullivan said.
 
‘This is why the conversations healthcare practitioners have with their patients are paramount to their recovery.
 
‘With an ageing population, growing obesity rates and an increasingly sedentary lifestyle, implementing the new clinical care standard is our best chance to remove barriers to good patient outcomes.
 
‘The recommendations aim to reduce investigations and treatments that may be ineffective or harmful.’
 
According to Associate Professor Marles, referring low back pain patients for imaging who don’t have any signs of a serious condition is an example of an unnecessary investigation that may lead to unnecessary concern or wrong care.
 
‘Common findings on back scans include disc degeneration, bulges and arthritis; yet these are often found on scans of people who do not have back pain – so these findings can be unhelpful and misleading,’ she said.
 
‘The good news is that most people who have a single episode of low back pain – 75% of patients – will improve rapidly and their pain will resolve within six weeks.
 
‘With this new standard, we are aiming to break the cycle and prevent a new episode of low back pain becoming a chronic problem for many Australians.’
 
It is only when a patient is not recovering within six weeks, that practitioners should reassess and consider referral for additional targeted care, Professor O’Sullivan added.
 
The Low Back Pain Clinical Care Standard will be launched via webcast on Thursday, 1 September 2022 at 12 pm (AEST).
 
A ‘quick guide’ for GPs that includes a step-by-step checklist, as well as ‘communication tips’ for educating patients on the new recommended approach to treatment, has also been produced and is available on the Commission website.
 
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