Review of The Lancet Article: Low Back Pain: A Major Global Challenge (Part One)

Monday, April 2nd, 2018

This week, we are going do a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow.

Those of us that are hungry for new research and the recommendations that arise from the body of literature being constantly created were excited last week about the release of significant reports coming out in a highly respected research journal called The Lancet.

Founded in 1823, The Lancet is published weekly is one of the oldest, most respected, and most well-known medical journals in the world. When it was announced a series of papers were to be published in The Lancet having to do with low back pain, as you may imagine, those of us interested in the research world and musculoskeletal complaints were all ears.

Not only was the article noteworthy due to its being published in The Lancet, but it was also exciting for those of us in the so-called alternative healthcare world because there were several Doctors of Chiropractic sitting on the steering committee for the series of reports. For some reason, chiropractors are still considered by many to be alternative, while this group of papers suggest chiropractic may be a lot more than simply “alternative.”

We chiropractors are typically not sitting at the table when the bigger discussions or decisions are made so, thanks to research that has been done prior to this, we are in the thick of it now it seems. And that is exciting to say the least.

There are a couple of things in my mind that stand out as reasons for such a series of papers. The first being that low back pain has become a major problem globally and shows no sign of stopping the growth of its impact. The second reason would be the ineffectiveness of the treatments commonly used or recommended. This includes surgery, epidural steroid injections, and, the most notable of failed treatments, opioids.

The series of Low Back Pain papers were compiled by a team of leading experts on back pain. The team was made up of an international spectrum of varied backgrounds. They met for a workshop in Buxton, UK, in June, 2016 to start the journey and the process of setting the outline and some sort of structure for each paper.

It was quite an undertaking from quite the group of experts. This is not a group of papers to be ignored since these authors and researchers are among the best of the best globally.

The papers were broken down as follows:

  1. What low back pain is and why we need to pay attention.
  2. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  3. Low back pain: a call for action.

In this article, I will cover the first of the three papers with plans to highlight the next two papers in the coming weeks so be sure to return for those important discussions.

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

  • MEDLINE (PubMed)
  • Scopus
  • Google Scholar
  • African Index Medicus Database

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Summary of the introduction of the first paper.

  • Low back pain is now the leading cause of disability worldwide.
  • Only a small percentage have a well-understood, definite cause for their low back pain. Examples of well-known and understood causes are things like a vertebral fracture, malignancy, or infection.
  • Things that seem to raise the risk of having low back pain complaints would be populations that smoke regularly, people that have physically demanding jobs or routine jobs or jobs that keep them mostly sedentary throughout the day and throughout the work week, people with physical and mental issues that add to a low back complaint or contribute to a low back complaint, and overweight/obese people. These populations are all at risk for developing low back pain.
  • 540 million people were affected at any one time globally.
  • A systematic review (3,097 participants) found several MRI findings had a reasonably strong association with low back pain, including Modic type 1 change, disc bulge, disc extrusion, and spondylolysis. To further define Modic 1 changes, in regular vertebral endplate bone, the trabeculae should be like a type of scaffolding. Within the trabeculae there is red bone marrow producing blood cells. In a Modic type 1, the trabeculae are fractured intermittently and the patterns are more erratic and the marrow is absent. In the marrow’s place now is serum which is the same substance one can find in a blister.

Symptoms Associated With Low Back Pain

Radicular Pain and Radiculopathy

  • Radiculopathy is usually called sciatica and mostly occurs when there is involvement where the nerve root exits the spine.
  • The authors noted that the term sciatica is used inconsistently by doctors and the public in general and should probably be avoided all together.
  • The diagnosis of radicular pain relies on clinical findings, such as history of dermatomal leg pain, leg pain that is actually worse than the back pain, aggravation of the symptom when bearing down such as in coughing, sneezing, lying on your back and raising heels off of the table or in going from seated to standing, and straight leg raise test. The general rule of thumb for an SLR is that pain in the first 30 degrees of leg elevation hints at a disc origin, since that is the movement that first starts to tension the nerve at the root.
  • Radiculopathy is not just the feeling of pain. Radiculopathy can also be weakness, decreased sensation, decreased reflexes, or all of those combined. In addition they can be identified with, or without, the presence of pain.
  • Patients presenting with low back pain in addition to radicular pain or radiculopathy tend to have worse outcomes than those presenting with low back pain alone.

Lumbar Spinal Stenosis

  • I tell my patients that the simplest way to explain stenosis is to say that a hole that nerves runs through has become smaller and as a result, the nerves sometimes have pressure on them that can cause them to be somewhat dysfunctional.
  • Lumbar spinal stenosis is clinically characterized by pain or discomfort with walking or standing that radiates into one or both legs and can be eased when resting and almost always by lumbar flexion (neurogenic claudication). They call this the shopping cart sign. Meaning, if a person gets relief from leaning on a shopping cart, it sure may be stenosis. If it is aggravated by leaning back or by inducing a “swayback” type of movement, that sure may be stenosis. As a side note and from my own studies, if lumbar extension (or swayback) does not hurt, but then rotation in either direction at the endpoint of lumbar extension actually does increase the pain, then the patient is likely suffering from a lumbar facet complaint.
  • Lumbar stenosis is commonly caused by narrowing of the spinal canal or intervertebral foramina as a result of a combination of degeneration such as facet osteoarthritis, ligamentum flavum hypertrophy, and bulging discs. Two or three of these factors can combine to reduce the size and space available for the neural structures to pass through. Obviously that can create issues.
  • Experts tend to agree that the diagnosis of stenosis requires both the presence of the symptoms in addition to imaging findings demonstrating stenosis.

Other Causes of Low Back Pain

  • Vertebral fracture, inflammatory disorders, malignancy, infections, intra-abdominal causes.
  • The US guideline for imaging advises deferral of imaging pending a trial of therapy when there are weak risk factors for cancer or axial spondyloarthritis. What does that mean exactly? That means a trial of conservative care. The authors will delve further into this in the second paper from the Lancet series but I will butt my head in here with the opinion of the American College of Physicians. Their updated recommendations from February of 2017 reflect that doctors should be recommending Chiropractic, massage, and/or ice for acute low back pain and should recommend Chiropractic, acupuncture, and/or exercise/rehab for chronic low back pain. These recommendations are to precede taking even ibuprofen.

Prevalence

  • Approximately 40% of 9 through 18-year olds in high-income, medium-income, and low-income countries report having had low back pain.
  • Low back pain prevalence increased 54% since 1990.
  • It is the number one cause of disability globally.

Work Disability

  • Jobs are less-regulated in lower and middle income countries. Many times, employers and companies are unwilling to modify the job duties or the workload. As a result, having low back pain can be particularly concerning or difficult for an employee in these circumstances.
  • To go along with jobs that are poorly regulated, heavy manual labor has no regulation or proper safety instruction adding to low back pain injury instances.
  • In Europe, low back pain is the most common cause of medically certified sick leave and early retirement.
  • In the USA, low back pain accounts for more lost workdays than any other occupational musculoskeletal condition.

Social Identity & Inequality

  • MacNeela and colleagues reviewed 38 separate qualitative studies in high-income countries. They showed common traits, including worry and fear about the social consequences of chronic low back pain, hopelessness, family strain, social withdrawal, loss of job and lack of money, disappointment with health-care encounters (in particular with general practitioners), coming to terms with the pain, and learning self-management strategies.
  • Froud and colleagues reviewed 42 qualitative studies from high-income countries, and found that many people living with low back pain struggled to meet their social expectations and obligations and that achieving them might then threaten the credibility of their suffering, with disability claims being endangered. Sometimes we have to almost force low back patients back into the workforce and, did you know that studies show in general that the sooner people are returned to work, the better they tend to recover from the low back pain complaint?
  • Schofield and colleagues found that individuals who exit the workforce early as a result of their low back pain have substantially less wealth by age 65 years, even after adjustment for education. This is just an obvious statement. It makes sense that people that quit working earlier than 65 end up making less money by the time they reach 65. You can also throw the expense of dealing with a back pain complaint in on top of the loss of wages.
  • Globally, low back pain contributes to inequality. At first, when I read this, it struck me as being silly. Everything’s about inequality these days isn’t it? Certainly in America it seems. But, this is a little different when you read through the explanation. The authors go on to say that in low-income and middle-income countries, poverty and inequality might increase as participation in work is affected. In addition, regulations on how to properly re-introduce a person into the workforce are absent, and workers are likely to be placed right back into the job they were originally injured without proper re-introduction. The authors felt this might place more strain on family and community livelihoods.

Cost of Low Back Pain

  • Costs associated with low back pain are commonly tallied as direct medical costs, meaning the cost of the doctor’s bill. They are also tallied in terms of indirect costs, meaning the cost of being out of work and the loss of productivity at the workplace.
  • Most studies underestimate the total costs of low back pain.
  • Although we do not think of low back pain in these terms yet, the truth is that low back pain, in terms of a real problem as far at the cost to treat and the overall indirect costs, are right up there with the biggest issues the global population faces. Issues such as cardiovascular disease, cancer, mental health, and autoimmune diseases. That’s huge.
  • In the USA, 44% of the population used at least one complementary or alternative health-care therapy in 1997; and the most common reason was low back pain. With 70,000 plus chiropractors in the United States, I can tell you with some confidence the profession most associated with alternative treatment for low back pain or spinal pain of any sort is chiropractic care.
  • The USA has the highest costs, attributable to a more medically intensive approach as well as higher rates of surgery compared with other high-income countries. We see patients every week that have gone through needless surgeries. Surgeries for which there is plenty of high-level research proving its ineffectiveness, yet you see the popularity for these surgeries continuing to rise.

Natural History

  • A systematic review (33 cohorts; 11,166 participants) provides strong evidence that most episodes of low back pain improve substantially within 6 weeks, and by 12 months average pain levels are low. However, two-thirds of patients still report some pain at 3 months and 12 months.
  • The best evidence suggests around 33% of people will have a recurrence within 1 year of recovering from a previous episode.

Risk Factors and Triggers for Low Back Pain Episodes

  • A systematic review (5,165 participants) found consistent evidence that people who have had previous episodes of low back pain are at increased risk of a new episode. Likewise, people with other chronic conditions, including asthma, headache, and diabetes, are more likely to report low back pain than people in good health.
  • A UK cohort study found psychological distress at age 23 years predicted incident low back pain 10 years later. The Canadian National Population Health Survey with 9,909 participants found that pain-free individuals with depression were more likely to develop low back pain within 2 years than were people without depression systematic reviews of cohort studies indicate that lifestyle factors such as smoking, obesity, and low levels of physical activity that relate to poorer general health are also associated with occurrence of low back pain episodes. We know that obesity and lack of exercise has become an American trait that needs to be reversed.
  • A systematic review found the genetic influence on the liability to develop low back pain ranged from 21% to 67%, with the genetic component being higher for more chronic and disabling low back pain than for inconsequential low back pain. Don’t we all have patients that present to us claiming that their bad back just runs in the family? Mom and Grandma had a bad back so that must be why they have a bad back is the common sentiment. It seems there may be a bit of validity there.
  • An Australian case-crossover study (999 participants) showed that awkward postures, heavy manual tasks, feeling tired, or being distracted during an activity were all associated with increased risk of a new episode of low back pain. Similarly, work exposures of lifting, bending, awkward postures, and tasks considered physically demanding were also associated with an increased risk of developing low back pain in low-income and middle-income countries.

Psychological Factors

The presence of psychological factors in people who present with low back pain is associated with increased risk of developing disability even though the mechanisms are not fully understood.

Social and Societal Factors

  • Cross-sectional data from the USA (National Health Interview Survey 2009–10, 5,103 people) found that those with persistent low back pain were more likely to have had less than high-school education and had an annual household income of less than US$20,000.
  • Suggested mechanisms for the effect of low education on back pain include environmental and lifestyle exposures in lower socioeconomic groups, lower health literacy, and health care not being available or adequately targeted to people with low education.
  • To go along with lower wages, the lower socioeconomic groups are commonly in routine and manual occupations and have increased physical workloads associated with disabling low back pain.

Conclusion

“Low back pain is now the number one cause of disability globally. The burden from low back pain is increasing, particularly in low-income and middle-income countries, which is straining health-care and social systems that are already overburdened. Low back pain is most prevalent and burdensome in working populations, and in older people low back pain is associated with increased activity limitation. Most cases of low back pain are short-lasting and a specific nociceptive source cannot be identified. Recurrences are, however, common and a few people end up with persistent disabling pain affected by a range of biophysical, psychological, and social factors. Costs associated with health care and work disability attributed to low back pain are enormous but vary substantially between countries, and are related to social norms, health-care approaches, and legislation. Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden.”

Source Material

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Authors

Steering Committee
Rachelle Buchbinder – Australia
Jan Hartvigsen – Denmark
Dan Cherkin – United States
Nadine Foster – UK
Chris Maher – Australia
Martin Underwood – UK
Maruits van Tulder – Netherlands

Did you know that research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic? Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

Please feel free to leave a comment and tell me your thoughts. I’d love to hear what you think. And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……
The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.

Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.
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http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext