The challenge of low back pain

The World Health Organization stated that in 2020 Low Back Pain (LBP) globally affected 619 million people and is cited as the single leading cause of disability worldwide (1).

The diagnosis of LBP is a challenging process in term of structure. There is generally an accepted lack of evidence to suggest that through specific examination or tests non-specific LBP will be found from anatomical structures (2), while in guiding prognosis, psychosocial factors are recommended as key features that will inform the clinical opinion (3).

MRI and x-ray are not recommended in the assessment of LBP (4), and it is clear that in cases where serious pathology is not diagnosed clinical practice needs to be multi-factorial and person-centred when working towards a diagnosis and management plan (5).

Treatments within physiotherapy have long since been exercise and ‘hands on’ driven, however physiotherapists are now encouraged to use a wider more cognitively informed approach to care (6). Studies that emphasise the multi-factorial approach that is directly person centred are showing a more fruitful potential, as for many years studies have failed to show one singular approach will work over another.

As physiotherapists trying to support patients with LBP, the improvement of psychological acceptance and education whilst working towards a clear supportive narrative approach is driving the profession to look beyond structure and consider the multitude of factors that can or cannot be modified to improve disability and outcome (6).

While the identification of red flags is vital, the understanding of the patient story and tailoring care to that need is where physiotherapists can offer advanced support. Acknowledging complexity as well as signposting appropriately are vital added physiotherapy skills as we begin to understand the influence of the wider social determinants of health and social value on how LBP will present across the healthcare sector (7).  

References

1 World Health Organization (2023) 
2 Kreiner, D.S., Matz, P., Bono, C.M., Cho, C.H., Easa, J.E., Ghiselli, G., Ghogawala, Z., Reitman, C.A., Resnick, D.K., Watters III, W.C. and Annaswamy, T.M., 2020. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. The Spine Journal, 20(7), pp.998-1024
3 Nieminen, L.K., Pyysalo, L.M. and Kankaanpää, M.J., 2021. Prognostic factors for pain chronicity in low back pain: a systematic review. Pain reports, 6(1), p.e919
4 National Institute for Health and Care Excellence 2020 
5 Lewis, J. and O’Sullivan, P., 2018. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British journal of sports medicine, 52(24), pp.1543-1544.
6 Kent, P., Haines, T., O'Sullivan, P., Smith, A., Campbell, A., Schutze, R., Attwell, S., Caneiro, J.P., Laird, R., O'Sullivan, K. and McGregor, A., 2023. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet, 401(10391), pp.1866-1877.
7 Karran, E.L., Grant, A.R. and Moseley, G.L., 2020. Low back pain and the social determinants of health: a systematic review and narrative synthesis. Pain, 161(11), pp.2476-2493.