Some quick fixes for lower back pain

If you’ve ever adjusted your lower back, you’re in the majority. Most people will experience this at some point in their lives. And all over the world, across all age groups and genders, low back pain is the most common leading cause of disability.

Of course, not everyone is affected equally. Low back pain is more common in girls and women, and in older people. The condition is also more serious among these groups, while low back pain is a one-off, relatively mild situation for most people.

There are also socio-economic links with low back pain. In a vicious circle, it becomes more common among poorer people and contributes to poverty through factors such as inability to work and early retirement.

The number of cases of low back pain is increasing significantly. One in thirteen people experienced this in 2020, an increase of 60% over 30 years. An important reason is that the population is getting older. Episodes of low back pain are more common in older people. If symptoms persist for the past three months, it is considered a chronic condition.

“With our aging population in the developing world, this problem will become worse,” warns Mary Cardosa, a pain specialist at Hospital Selayang and the Ministry of Health in Malaysia. She is also a member of the Developing Countries Working Group of the International Association for the Study of Pain.

In the most severe cases, lower back pain ruins lives. Patients may become housebound and no longer be able to urinate normally. Relationships can be damaged. The effects can intertwine and intensify. “Many people with chronic pain isolate themselves, also work sensibly and that can affect their financial status, which can then lead to family problems,” says Cardosa, who has run a pain clinic for the past two decades.

Furthermore, it can increase hardship if it is not clear why someone is experiencing this pain. “One of the important components of our treatment is always to help them understand what is happening to them, why they have back pain,” says Cardosa. But tests cannot clarify this. “This is something that bothers patients a lot, causing them to seek help from many different healthcare professionals.”

Given the severity of this health problem, the World Health Organization developed a unique system in December 2023 guidelines for the non-surgical treatment of chronic back pain in adults. (Cardosa was part of the group that developed them.) The guidelines are detailed in a massive 274-page document, but for anyone not inclined to read every word of it, here are some key points:

• The main recommendation applies to mobility aids, including canes, crutches, walkers, mobility scooters and wheelchairs. (Cardosa notes: “In the Asian context, our old ladies come to our pain clinic with an umbrella instead of a cane because they say if I carry a cane I look too old.”)
• Structured exercises, needles and messages can be helpful; the WHO has lukewarm recommendations for these common practices.
• Paracetamol, which does nothing against inflammation, is no more effective than a placebo.
• Lumbar braces, belts and supports are not recommended.

Yuka Sumi, medical officer at the WHO Aging and Health Unit, said“Specific treatments may include effective self-care, physical therapies such as exercise and massage, psychological therapies that can help you focus on what you can do, not the pain, and anti-inflammatory medications.”

However, there seems to be more evidence for what not work. According to Sumi“Manual therapies such as traction or some electrotherapies such as ultrasound, the use of electrical current, lumbar braces and some medications… for example, do not work, such as antidepressants and muscle relaxants.”

Partly because so many proposed remedies aren’t necessarily effective, Cardosa’s job largely involves managing people’s expectations. Low back pain often cannot be traced back to a single, easily addressed problem. And one-off treatments often don’t work. “I see the value of managing the person as a whole with a multimodal approach,” says Cardosa. “There is little point in looking at treatments separately.”

Part of this is the responsibility of researchers to study the effectiveness of more complex treatments. “I think we’ve always been too simplistic in looking for treatments for chronic pain: trying to look for one solution because there isn’t one solution,” Cardosa notes. “So we really should do more research into combinations of treatments.”

When it comes to healthcare professionals’ responsibilities, insufficient time and resources can hinder the thorough assessments needed to fully understand patients’ experiences. A specific task is to explain how low back pain can affect the rhythm of people’s day, possibly for a long time. In Cardosa’s experience, some health professionals overlook chronic back pain and treat it as acute because some people actually do not realize that their pain is chronic, that they have had it for a long time.

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

In other words, people should not overdo it when the pain is less, because that can cause a new flare-up of the pain. “You have to do things according to your plan, rather than according to your pain,” Cardosa emphasizes.

These messages can be disappointing for people who want their pain to be gone forever. But Cardosa has an optimistic message: “Although chronic back pain is common, not all people with chronic back pain or chronic pain are disabled.” Although this will depend on the individual’s circumstances, some form of relief and return to activities is possible for many people. But it’s safest to keep expectations realistic.