Few Quick Fixes For Low Back Pain

If you’ve ever tweaked your lower back, you’re in the majority. Most people will experience this at some point in their lives. And around the world, for all age groups and genders, low back pain is the main cause of disability.

Not everyone is equally affected, of course. Low back pain is more common in girls and women, and in older people. It’s also more serious among these groups, whereas for most people low back pain is a one-off, relatively mild situation.

There are also socioeconomic links with low back pain. In a vicious circle, it’s both more common among poorer people, and a contributor to poverty through factors like inability to work and early retirement.

Cases of low back pain are increasing substantially. One in 13 people experienced it in 2020, a 60% increase over 30 years. A key reason is that populations are getting older. It’s in older people that episodes of low back pain become more frequent. If symptoms persist past three months, it’s considered a chronic condition.

“With our aging population in developing countries, this problem is going to get bigger,” warns Mary Cardosa, a pain specialist at Hospital Selayang and the Ministry of Health in Malaysia. She’s also a member of the Developing Countries Working Group of the International Association for the Study of Pain.

In the most severe cases, low back pain ruins lives. Sufferers can become housebound, unable to urinate normally. Relationships can be harmed. The effects can entangle and intensify. “A lot of people with chronic pain isolate themselves, also work wise and then that can affect their financial status, which then can snowball to family issues,” says Cardosa, who has been running a pain clinic for the past two decades.

Further, it can add to the hardship when it’s not clear why someone is experiencing this pain. “One of the important components of our treatment is always to help them to understand what’s happening to them, why do they have back pain,” Cardosa says. But tests may not illuminate this. “This is something that distresses patients a lot, and makes them come seek treatment from many different healthcare professionals.”

Given the seriousness of this health issue, in December 2023 the World Health Organization developed first-of-their-kind guidelines on non-surgical management of chronic back pain in adults. (Cardosa was part of the group that developed these.) The guidelines are elaborated in a mammoth 274-page document, but for anyone disinclined to read every word of this, here are some key takeaways:

• The main recommendation is for mobility assistive products, which can include canes, crutches, walking frames, mobility scooters, and wheelchairs. (Cardosa notes, “In the Asian context we get our old ladies coming to our pain clinic carrying an umbrella instead of a walking stick because they say if I carry a walking stick, I look too old.”)
• Structured exercise, needling, and message could be helpful; the WHO has lukewarm recommendations for these common practices.
• Paracetamol, which doesn’t do anything for inflammation, is no more effective than a placebo.
• Lumbar braces, belts, and supports aren’t recommended.

Yuka Sumi, a medical officer in the WHO’s Ageing and Health Unit, has said, “Specific treatments might include: effective self-care, physical therapies such as exercise and massage, psychological therapies that can help you to focus on what you can do, not on the pain, and anti-inflammatory medicine.”

However, there appears to be more evidence of what doesn’t work. According to Sumi, “For instance, manual therapies such as traction or some electrotherapies such as ultrasound, using electric current, lumbar braces, and some medicines...do not work, such as anti-depressants and muscle relaxants.”

In part because so many suggested remedies aren’t necessarily effective, much of Cardosa’s job is about managing people’s expectations. Low back pain often can’t be traced to a single, easy-to-tackle issue. And one-off treatments often don’t work. “I see the value of managing the person as a whole with a multi-modal approach,” Cardosa says. “Looking at treatments in isolation doesn’t make a lot of sense.”

Part of this is a responsibility of researchers, to study the effectiveness of more complex treatments. “I think that when we look for treatments for chronic pain, we have always been too simplistic: trying to look for one solution because there is no one solution,” Cardosa observes. “So we really should be doing more studies on combinations of treatments.”

In terms of health workers’ responsibilities, insufficient time and resources can hinder the thorough assessments needed to properly understand patients’ experiences. One specific duty is to explain how low back pain can affect the rhythm of people’s days, potentially for a long time. In Cardosa’s experience, some health workers will miss chronic back pain and treat it as acute because certain people actually don’t realize that their pain is chronic, that they’ve been suffering for a long time.

The nature of chronic pain is that it fluctuates, Cardosa notes. “Every person with chronic pain will tell you that I have good days and bad days. So they need to know how to deal, how to try and flatten the curve, not have such great variations in the level of pain. And that’s using techniques like pacing out the activities, building up tolerance slowly step by step and things like that.”

In other words, people shouldn’t overdo it when the pain is lower, because that could cause another flare-up of pain. “You have to do things according to your plan, rather than according to your pain,” Cardosa emphasizes.

These messages may be disappointing for people who want their pain to be gone now, forever. But Cardosa has an optimistic message: “Even though chronic back pain is very prevalent, not all people with pain with chronic back pain or chronic pain are disabled.” Though it will depend on individuals’ circumstances, for many people, some form of relief and return to activities are possible. But it’s safest to keep expectations realistic.