Introduction and Epidemiology
Low back pain (LBP) is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by LBP increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. LBP is now the leading cause of disability worldwide.
It has profound effects on well‐being and is often the cause of significant physical and psychological health impairments. LBP also affects work performance and social responsibilities, such as family life, and is increasingly a major factor in escalating health‐care costs. A global review of the prevalence of LBP in the adult general population has shown its point prevalence to be approximately 12%, with a one‐month prevalence of 23%, a one‐year prevalence of 38%, and a lifetime prevalence of approximately 40%.
Most people with new episodes of LBP recover quickly. However, recurrence is common and in a small proportion of people, LBP becomes persistent and disabling. Disability and costs attributed to LBP are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of LBP as a public health problem.
Support for the principles of evidence-based medicine has increased over the past decade. The field of LBP is a good example of this development, with the publication of many randomized trials and systematic reviews evaluating a broad range of commonly used conservative and complementary treatments. Evidence-based medicine is a shared issue for both conventional medicine and complementary and alternative medicine (CAM). Moreover, CAM research is growing steadily. The number of randomized trials of CAM has been doubling approximately every 5 years.Some of these modalities include Chiropractice, Acupuncture, Yoga, Thermal therapy and Cognitive Behavioral Therapy.
Low back pain causes are commonly nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. Some mechanical causes would include degenerative processes of disks and facets, herniated disk, osteoporotic fracture, spinal stenosis, traumatic fracture. Non specific back pain, on the other hand, generally refers to lumbar sprain or strain.
Some red flags to consider would include significant trauma, a major or progressive motor or sensory deficit, new onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, loss of sensation of area of buttocks, perineum and inner thighs, history of cancer metastasis to bone, and suspected spinal infection. It is important to also rule out any constitutional symptoms such as loss of weight, loss of appetite, fever, chills, rigours, night sweats and night pain that wakes you up from sleep. These symptoms should prompt you to check with a medical professional, and only after ruling out these acute and/or insidious causes of back pain, can you term it as a non specific or idiopathic back pain, caused by lumbar sprain or strain. The article will mainly be discussing non specific back pain.
Should you encounter any of the red flags, it is vital that you seek early referral for surgical evaluation or other invasive procedures. However, in the case of non specific or idiopathic back pain, the conventional treatment is usually conservative. The prognosis is often good, with most cases recovering with little intervention. Staying active, avoiding bed rest, early return to normal activities and avoiding twisting and bending would greatly benefit the patient’s recovery. Pharmacological agents can also be opted, in the form of a trial of nonsteroidal anti-inflammatory drug or acetaminophen. Muscle relaxants or a short course of opioid therapy can be used depending on the pain severity. If the pain is recurrent, referral to physical therapy can be opted instead.
For Chiropractic, spinal manipulative therapy is associated with significantly greater improvement in condition-specific functioning.Moreover, chiropractice maintenance care, though higher in number of treatments compared to symptom guided treatments, is more effective in reducing the number of days with bothersome non-specific LBP compared with symptom guided treatment. There are some absolute contraindications to chiropractice, which includes structural anomalies of the spine, acute fracture, spinal cord tumour, acute infection, tumours, heematomas, malignancy, disc herniation, radiculopathy and cauda equina syndrome.Moreover, should you seek chiropractic treatment, it is crucial to first obtain the relevant imaging(Plain radiographs or MRI) and consult your doctor.
Acupuncture has also shown many evidence based benefits in terms of LBP. It is safe and acceptable to refer patients to acupuncturists for a short course of treatment, and proves to be an important supplement of conservative orthopedic treatment in the management of chronic LBP. It can also be seen that acupuncture was more effective in improving pain than no acupuncture, and patients can try it to manage their pain. Some contraindications would include pregnancy, medical or surgical emergencies, malignant tumours and bleeding disorders. Others will include immunocompromised states and heart valve disease.
Yoga can serve to improve LBP as well. A long term yoga program to adults with chronic or recurrent LBP led to greater improvements in back function than usual care. Moreover, yoga improves functional disability, pain intensity and even depression in adults with chronic LBP.Yoga can also benefit in terms of improved spinal flexibility, and does so better than a physical exercise regimen. Indeed, yoga can function to improve the low back status of individuals. Specifically for low back pain, there are poses that individuals should avoid, which can be found online.
Thermal heat has also garnered much traction in terms of treating LBP. Heat wrap provides a small short term reduction in pain and disability. Additionally, trials show that combining continuous low heat wrap with directional preference-based exercise during treatment of acute low back significantly improves function. Overnight use of heat wrap itself relieved pain throughout the next day, and improved trunk flexibility.Clearly, there is a role of thermal heat in treatment, and improvement of function of individuals with LBP. Some contraindications for superficial heat and ultrasound sources include neoplasm, circulatory impairment, sensory problems, bleeding, acute trauma, over epiphyseal plate, over neural tissue, over reproductive tissue, pregnancy, cognition or communication impairments, infection, compromised skin integrity, edema or implants.
Cognitive behavioural therapy
Last but not least, cognitive behavioural therapy(CBT) can be used to improve pain. First of all, studies suggest that CBT is a credible, acceptable and promising way to treat people with LBP that are experiencing high levels of avoidance and distress. Research also shows that treatment with mindfulness-based stress reduction or CBT, compared with usual care, led to larger improvement in back pain and functional limitations. On the other hand, some intervention program shows modest effects of CBT in reducing LBP and disability over a 1 year period. No matter the study, CBT can have a role in improving the function and pain of individuals with LBP, especially those experiencing some form of psychosocial distress. Some contraindications would include patients with significant illness, such as severe mood disorder, individuals with very limited intellectual functioning. Also, CBT strategies should be modified/adapted for use with special groups, and CBT therapies should routinely monitor the need for alternative treatments for comorbid conditions.
Though the different modalities can serve to complement or even replace the usual treatments, it is important to stress that there are certain contraindications to the above modalities. First of all, individuals with medical emergencies should consult their healthcare provider before starting any of these programs. Moreover, there are individual contraindications for the various conditions that patients should always be wary of. Hence, do consult your physician before opting for alternative therapies.
LBP is a prevalent issue in the public, and alternative therapies can complement the various treatments that individuals are currently on. It is prudent to always check with the healthcare provider before attempting any of these, and ensure that the safety and well-being of individuals are kept.
- John Tan, National University of Singapore
- Ho Yi Jie, National University of Singapore
- Kaye Tan, Singapore University of Technology and Design
- Pham Trung Viet, Singapore University of Technology and Design