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SIMPLE, first-line care incorporating advice, reassurance and self-management is the mainstay in managing most cases of non-specific low back pain in primary care, say experts writing in the MJA this week.
In a Guideline Review, experts have summarised key recommendations from guidelines recently released in the UK, Belgium, Denmark and the US.
The guidelines have several new messages for clinicians, such as an emphasis on simple first-line care and early follow-up within 1–2 weeks. For patients who need second-line care, the researchers say that non-pharmacological treatments, such as physical and psychological therapies, should be tried before pharmacological options are considered. If drug therapy is used, it should be used at the lowest effective dose for the shortest time possible, the researchers advised.
Surgical and interventional procedures have been found to be ineffective, they wrote.
Messages from previous guidelines have also been reinforced in this latest advice, the researchers wrote. These include the avoidance of routine imaging, the use of a triage approach when classifying patients presenting with low back pain, and the use of advice, reassurance and self-management as the cornerstone in simple, first-line care.
For patients with chronic non-specific low back pain, exercise and/or cognitive behavioural therapy has been recommended in the latest guidelines, the researchers reported.
The review comes after a team of international experts, led by Monash University’s Professor Rachelle Buchbinder, published a three-part series on low back pain in The Lancet. The series called for an overhaul of treatment practices, some of which were harmful, and recognition of the disability caused by back pain globally.
Lead author of the MJA guideline review, Professor Chris Maher, from the University of Sydney’s School of Public Health, said that the MJA review was in harmony with the position taken in The Lancet series.
“The MJA article provides more guidance for clinicians in how they should go about treating patients, but the messages are very well aligned,” said Professor Maher, who also contributed to The Lancet series.
He said that the article was a follow-up to a Narrative Review on the triage of low back pain, published in the MJA late in 2017.
In an MJA InSight podcast, Professor Maher said that there was a significant shift in the primary care management of non-specific low back pain, which accounted for about 95% of low back pain seen in primary care.
“GPs won’t be prescribing medicines as often as they have in the past, referrals for imaging and surgery will be uncommon,” Professor Maher said. “They will be working with the physiotherapist and psychologist, and they will be managing their patients with a non-drug approach. [They will be] talking to their patients confidently, helping them structure their lives so they can get back to what they want to do.”
Professor Maher said that the approach was a return to “good, old-fashioned general practice”.
Professor Buchbinder welcomed the review, saying that it fitted well with the international push for change in the management of non-specific low back pain.
Professor Buchbinder, who was lead author on an article in The Lancet series issuing a “call to action” for broader societal change on low back pain management, said that there were challenges ahead for clinicians and for patients.
“Among doctors, there is always the worry that we will miss something serious, so I can well appreciate that such worry would sometimes drive people to referring for imaging. On the other hand, I think GPs do have a really good understanding of needing to exclude serious causes of back pain,” she said.
“Things have changed. We now don’t want to prescribe medication unless it’s absolutely essential, but it’s very difficult when you have a patient in front of you with severe pain to say ‘we’re not going to give you any medication’.”
Professor Buchbinder said that once GPs had excluded serious causes for back pain, they should seek to identify the patients for whom simple first-line care was appropriate.
“[The goal is] to identify early the majority of people who only need advice to stay active and on how to manage [the pain] themselves, and to stay physically active in the future,” she said.
At the same time, she said, it’s important to identify people at high risk of having persisting problems.
“We now want to stratify [these patients] to get the help that they need earlier, to try to prevent those persisting disability problems.”
Professor Buchbinder said that these people may need exercise education with a physiotherapist or cognitive behavioural therapy with a psychologist.
The MJA review highlighted several, freely available risk stratification tools to support GPs in identifying patients at risk of longer term problems. These tools include: STarT Back, Örebro Musculoskeletal Pain Screening Questionnaire and PICKUP.
Professor Maher said that recent guidelines had also warned of the limited diagnostic accuracy of some individual red flags, such as night pain.
“The contemporary approach relies on a smaller set of red flags than previously and emphasises the use of clusters of red flags along with clinical expertise to guide decision making,” Professor Maher and co-authors wrote in the MJA.
Professor Maher agreed that patient expectations could be a barrier to change. He said that he hoped that patient involvement in upcoming research efforts through the Australia and New Zealand Musculoskeletal Clinical Trials Network would help to overcome some of these challenges.
Further support for GPs will also be available from October when NPS MedicineWise launches a national educational program aiming to improve the management of low back pain. The program will focus on: clinical diagnosis of non-specific low back pain and the limited role of imaging; early identification of chronic pain and disability; and activity as a primary treatment option, with medication playing a secondary supportive role.
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I note the term “non-specific low back pain”. Does that mean we don’t have a diagnosis? That means limited history (or worse – poor history taking or none) and limited examination (or worse none). It really doesn’t matter what modality of treatment is, it won’t get better unless you have a precise diagnosis. Everything is then a “sham” unless you are targeting the pathology.
I rarely don’t have a diagnosis of the cause of pain. I will worry if my history or examination has not come up with the precise diagnosis.
Hi Dr Loutsky.
I’m afraid you have been ‘reading your own press’. Sham acupuncture is not a gold standard and was ddeclared as having a treatment effect in early 1990’s. Perhaps also read the siginificant literature and trials that carefully explain as well as prove – the treatment effect of sham needle acupuncture.
The first proof however starts with a trial on yourself. Please insert 10 needles through your skin and tell me that your pain system was not activated at all.
If however it was, then your have demonstrated to yourself that sham needle acupuncture has activated the pain system and is not a control intervention. Then apply that simple piece of ‘rationality’ (knowledge) to the trials that you refer to and let us all know.
Otherwise you can just use beta blockers for your next control intervention in a study on hypertension and see if it gets published.
Let us never underestimate the fundamental importance of the patient’s anatomy in evaluating “back pain”As emphasised ,the majority of our patients with back symptoms will present with poorly described and defined ” pain” .History taking has the potential to localise ,and therefore focus ,our assessment of clinical signs which should always include reflexes whatever the time restraints.Some may be less equipped to arrive at an accurate diagnosis simply because our anatomical concepts have failed a little. Without a detailed clinical examination of the patient , interpretation of the MRI is often unlikely to provide a successful ,lasting therapeutic outcome for both patient and medical practitioner.
Hi Anonymous. Just to complete the loop as you predicted – Level 1 evidence requires the existence of repeated/reproduced high quality studies clearly showing that an intervention worked better than a control, not a large number of small, methodologically fatally flawed studies that are designed to prove your pre-formed conclusions (that would be rated as Level 4 evidence). Sham acupuncture is the gold standard for a control when researching your beloved intervention, whether you like it or not. Other studies can demonstrate that the position of the needles (another form of sham control) makes no difference to the treatment “effect”, suggesting that the “mechanism of action” is probably not as purported. The small number of high quality studies all point to minimal or zero effect from Acupuncture when compared to controls. All the other studies are useless scientifically. There – I’ve “trotted out” the argument – you need to now explain what’s actually wrong with the argument…
I, for one, am thrilled that acupuncture is not being “trotted out” as an evidence-based option for back pain – refreshing rationality for a change.
Very well researched
Nothing we experienced GPs donot know
I totally agree with usefulness of acupuncture
I think this patient may benefit by care plan if have other chronic conditions
THIS BLLODY NUISANCE I AM NOT A ROBOT IS A PAIN IN NECK
HARD NOT TO BE CYNICAL:
Yet another document that carefully avoids the published meta-analysis Level 1 evidence for the use of acupuncture treatment for low back pain.
No doubt the usual reply will ensue – one that doesn’t understand that sham acupuncture is not a control intervention- and that these studies are not scientific. But of course the argument will be trotted out again.
Good luck with the politics of science; its working well.