Dr. Andrew Arnold discusses the need for a paradigm shift in the management of low back pain.
Low back pain (LBP) is a leading cause of disability globally. 
With regard to the treatment of LBP symptoms, we have seen a significant increase in spinal injections, pharmaceutical drug therapy including opioids and, more recently, spinal cord implants. It is believed these medical interventions are limited in their long-term benefits and may also carry important health risks. [2,3]
Concurrently, allied health modalities treating LBP has grown. Whilst some purport to address the ‘cause’, the majority are still symptom focused. These include dry needling (Myotherapy, Chiropractic, Physiotherapy, Acupuncture), spinal manipulation (Chiropractic, Osteopathy, Physiotherapy), soft tissue techniques (e.g. Remedial massage, Myotherapy), electrotherapy (e.g. Physiotherapy) and taping (e.g. Physio and Myotherapy) etc. Random controlled trials and other research reports insufficient, short-term benefits. It is further reported the underlying mechanisms predominantly neurophysiological as opposed to biomechanical / bio-structural. [4,5]
We have also witnessed a rise in exercise, prescriptive interventions in the management of LBP, e.g. core stabilisation exercises, balance techniques and focused regional exercise advice. The goals have been described as helping with mobility, joint subluxation and misalignment and other somatic aberrations. Again randomised controlled trials have reported little significant long-term effect and certainly has not been able to discern one form of exercise prescription over another. [6,7].
To complicate the picture further, ergonomic authorities persist in purporting that backs must be protected, that it’s about sitting upright, not bending over and in some cases using a back support despite the evidence based research in this area as poor. 
All this creates a pressured and threatened environment for the LBP patient perpetuating confusion and fear. The result is a dis-empowered state of mind where the patient feels weak, vulnerable and at risk of injury. 
So, there needs to be a paradigm shift in the management of LBP which leads me to this statement. There is growing evidence LBP is a multidimensional disorder! 
It appears where the evidence is showing up is around nonspecific factors, including the patient-doctor relationship, the patient’s expectations and beliefs, the practitioner’s confidence and experience, the patient’s mental and emotional state, and their ability to manage pain. These factors seem more reliable predictors of clinical outcomes in LBP management. [8,9,10]
An individual’s pain levels, distress and coping strategies are influencing their levels of disability. [14,15]
This is not necessarily revolutionary, however, it is certainly significant. ‘It underpins the urgent need for a multidimensional clinical-reasoning approach to patient examination and management to identify the various and relevant underlying drivers of pain and disability for each individual.’ [16,17,18]
O’Sullivan et al. describe a 3 step approach to managing LBP:
- Help the patient understand their pain, why is it there, what has caused it, how can they moderate it.
- Controlled rehabilitation so as to avoid fear of relapse and return of symptoms.
- Supporting and guiding lifestyle change to facilitate pain resolution.
So, there is growing evidence there needs to be a shift in the management of LBP!
What does this mean?
- Improving clinical skills in patient management.
- Exploring the patient’s psycho-social environment.
- Appreciating the multi-factorial nature of the patients pain.
- Understanding the patient’s behaviour in relation to their pain response.
- Educating the patient around pain management.
- Using physical therapies by way of validation and reassurance in addition to pain specific treatment.
- Collaborating with the patient with regard to healthy lifestyle behaviors, thereby empowering the patient.
The ultimate ‘ the best practice’ is a patient centred, multi-dimensional approach to LBP management.
There is growing evidence suggesting that current practice is not aligned with contemporary evidence and that this may be making things worse!
O’Sullivan et al. says, ‘Change will demand a cultural shift in LBP beliefs and practice.’
 Cowell I, O’Sullivan P, O’Sullivan K, Poyton R, McGregor A, Murtagh G, 2019. The perspective of physiotherapists on managing nonspecific low back pain follows a training programme in cognitive functional therapy: A qualitative study. Musculoskeletal Care 17:1, 79-90.
 Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC. Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database Syst Rev. 2013:CD004959. http://dx.doi. org/10.1002/14651858.CD004959.pub4
 Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila, Pa 1976). 2009;34:49-59. http://dx.doi.org/10.1097/ BRS.0b013e3181909558
 Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004:CD000447. http://dx.doi. org/10.1002/14651858.CD000447.pub2
 Hestbaek L, Korsholm L, Leboeuf-Yde C, Kyvik KO. Does socioeconomic status in adolescence predict low back pain in adulthood? A repeated cross-sectional study of 4,771 Danish adolescents. Eur Spine J. 2008;17:1727-1734. http:// dx.doi.org/10.1007/s00586-008-0796-5
 Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of nonspecific low back pain. Cochrane Database Syst Rev. 2005;3:CD000335. http://dx.doi. org/10.1002/14651858.CD000335.pub2
 Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15:416. http:// dx.doi.org/10.1186/1471-2474-15-416
 Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90:1099-1110. http://dx.doi.org/10.2522/ ptj.20090245
 Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive, behavioral treatment in chronic low back pain. J Pain. 2006;7:261-271. http://dx.doi. org/10.1016/j.jpain.2005.10.011
 Testa M, Rossettini G. Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes. Man Ther. 2016;24:65-74. http://dx.doi.org/10.1016/j.math.2016.04.006
 Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal, assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J. 2010;10:76-88. http://dx.doi.org/10.1016/j.spinee.2009.06.005
 Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine (Phila, Pa 1976). 2015;40:842-850. http://dx.doi. org/10.1097/BRS.0000000000000901
 O’Sullivan P. It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med. 2012;46:224-227. http:// dx.doi.org/10.1136/bjsm.2010.081638
 Andrews NE, Strong J, Meredith PJ. Activity, pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93:2109-2121.e7. http://dx.doi.org/10.1016/j.apmr.2012.05.029
 Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behaviour and their consequences for clinical practice. Clin J Pain. 2010;26:747-753. http://dx.doi.org/10.1097/ AJP.0b013e3181e104f2
, O’Keeffe M, Purtill H, Kennedy, N, et al. Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial. BMJ Open. 2015;5:e007156. http://dx.doi.org/10.1136/ bmjopen-2014-007156
 Vibe, Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain: a randomised controlled trial. Eur J Pain. 2013;17:916-928. http://dx.doi. org/10.1002/j.1532-2149.2012.00252.x
 O’Sullivan P, Caneiro P, O’Keefe P, O’Sullivan K, Unraveling the Complexity of Low Back Pain, J Orthop Sports Phys Ther 2016;46(11):932-937. doi:10.2519/jospt.2016.0609
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