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What’s the best way to manage low back pain?

According to the first Low Back Pain Clinical Care Standard, released last week by the Australian Commission on Safety and Quality in Health Care, people experiencing the condition should steer away from bed rest and painkillers and instead focus on physical activity and addressing potential psychological barriers to recovery, such as thoughts and emotions about pain.

One in six Australians experience low back pain, a leading cause of disability worldwide. In 2018-19, more money was spent on managing musculoskeletal disorders, including back problems, than any other category of disease, condition or injury in Australia.

According to the new standard, which aims to improve the early assessment, management, review and referral of patients with the common condition, the use of imaging tests, bed rest, painkillers and surgery play a limited role in managing most people’s low back pain.

Rather, it suggests an active approach, including self-management strategies and exercise, provides more benefit, and less risk, for patients.

The new standard provides a roadmap for healthcare practitioners 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.

Research shows many patients with low back pain avoid physical activity and work, and potentially become fearful, depressed or anxious, which can lead to higher risk of disability. This can reinforce unhelpful beliefs and responses to pain.

Clinical lead for the new standard, Associate Professor Liz Marles, Clinical Director at the Commission and a GP, said the standard marks a leap forward in effective care for low back pain patients, who commonly receive treatment from numerous health disciplines, including GPs, chiropractors and physiotherapists, and often receive conflicting advice.

Developed in consultation with clinicians, researchers and consumers, the standard includes statements describing the care that should be provided and a set of indicators to support monitoring and quality improvement.

“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,” Associate Professor Marles says.

“Also, if pain medicines are prescribed, they should be used to enable physical activities to help people recover, rather than eliminate pain.”

For people with a new episode of low back pain, a thorough initial assessment should be undertaken, Associate Professor Marles stresses. This should include screening for serious underlying causes such as cancer, infections or nerve compression. However, the risk of a serious cause is low (1-5%) and usually identified through history and physical examination, meaning investigations can sometimes paradoxically delay recovery.

“Referring low back pain patients for imaging who don’t have any signs of a serious condition may lead to unnecessary concern or wrong care,” she explains.

“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.”

In positive news, Associate Professor Marles says most people who experience a single episode of low back pain – 75% of patients – will improve rapidly and their pain will resolve within six weeks. For others, however, the condition can become chronic and affect a person’s ability to work and engage in physical and social activities, as well as their mental health.

Associate Professor Liz Marles, Clinical Director at the Commission and a GP

“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,” she says.

Professor Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, is another advocate for tailoring care to the needs of patients who experience low back pain, arguing that there needs to be consistency in how early back pain is managed across professions.

“Low back pain is one of the most feared health conditions,” he says.

“We have a societal problem around the fundamental beliefs about back pain. 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.”

While low back pain can cause significant discomfort and suffering for some people, Professor O’Sullivan highlights that it is important to reassure patients that they have a good chance of recovery.

Clinicians should educate their patients and provide a clear recovery plan with self-care options that build people’s confidence in their back and put them in charge of their health, through knowledge, exercise, physical activity and work.

“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.”

Access the Low Back Pain Clinical Care Standard here