Back pain: What really works?

With such a high prevalence of back pain in the community it's no wonder there are so many treatment options, some effective, others not.

Back pain is a significant health concern in Australia costing more than $40 billion annually and affecting around 16% of people at any given time.[i] It’s a condition that approximately 80% of us will experience at some time in our life. With such a high prevalence it’s no wonder there are a plethora of treatment options, some effective and others not.

The good news is that there’s considerable research evaluating the efficacy of various treatments and preventative strategies. For workplace practitioners involved in helping people recover at work, this is vital information which should inform decision-making. 

Clinical guidelines published in the Lancet medical journal in 2018 are based on a review of Australian and international literature. These guidelines represent the ‘gold standard’ for back pain management and physiotherapists, doctors and other health professionals have a responsibility to base their practice on these guidelines[ii]:

  • Provide education and advice to encourage people with back pain to remain physically active and to stay at work. The benefits of work are well documented for recovery. Many of us would relate to a time when we’ve felt unwell, either physically or mentally, and found the distraction of work to take us away from our pain. Concerningly, a review of Australian GP practice from 1997-2004 showed that up to 25% of GPs endorsed the incorrect view that patients should not return to work until they are almost pain free.
  • Exercise is recommended for chronic low back pain. This can be challenging to implement when people are in pain, but there is strong evidence to show this works and it requires a tailored approach to exercise, not simply joining the gym. Concerningly, Medicare funding has a limit of 5 allied health consultations per year and this is often insufficient to deliver an exercise program for chronic low back pain management.
  • Investigations should only occur if a different condition is suspected that requires different management to that of back pain eg. malignancy. The suspicion of a disc prolapse or spinal stenosis is not a reason to order imaging because clinical guidelines remain the same regardless of the finding. In fact, the confirmation of the presence of common conditions such as disc degeneration or facet joint arthritis can be incredibly damaging for a person’s recovery. The reality is that if investigations are conducted such findings are likely in people with and without back pain.   
  • Spinal fusions, radiofrequency neurotomy, facet joint injections, epidural injections and other medical procedures demonstrate “little or no benefit and have a very limited role, if any, in the management of low back pain” (Lancet 2018).

Professor Mark Hancock from Macquarie University is leading a research team looking at how we can best help people recover from back pain. The research suggests there are 3 categories of patient with low, medium and high risk of chronicity.[iii]

For the low risk patients, there is little or no treatment needed and their recovery time is similar with or without treatment. The medium risk group shows a reduction in recovery time with standard physiotherapy inclusive of exercise and education. The high-risk group benefited from “psychologically informed physiotherapy”. This is physiotherapy that focusses not only on exercise and movement, but also educates patients in strategies to improve their confidence in self-management, to understand the role of stress and anxiety, to appreciate the way in which movement can over-ride pain messages and how mood can influence pain.

For workers suffering back pain and struggling with their return to work, it can be helpful to review their treatment and ensure they are getting good advice. Case conference with GPs can be a useful adjunct to promote appropriate return to work. Workplace-based treatment can be provided to help workers develop self-management strategies and to see work as a type of gym program that will help their gradual increase in function and recovery. 

[i] Australian Institute of Health and Welfare (2018) Web report: Back pain snapshot

[ii] Foster et al (2018) Prevention and treatment of low back pain: Evidence, challenges and promising direction. Lancet 391: 2368-83

[iii] Hill et al (2011) Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378(9802):1560-1571