Physio findings: research highlights gaps in knowledge of effectiveness of back pain techniques

Caroline White and Lynn Eaton on the latest physio research findings.

Health experts need to find cost-effective and context-specific strategies for managing low back pain if they are to reduce the future burden of the disease, according to three papers published by The Lancet.
The papers, written on behalf of The Lancet Low Back Pain Series Working Group, look at the impact of this leading cause of disability worldwide. This international group includes CSP member Nadine Foster from Keele University, one of the papers’ lead authors.
Professor Foster suggests there is limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery.
She also looks at what evidence there is to show how effective various interventions are, globally, for preventing and treating low back pain and the recommendations from best practice guidelines.
‘In many countries, painkillers that have limited positive effect are routinely prescribed for low back pain, with very little emphasis on interventions that are evidence based such as exercises,’ said Professor Foster. 
‘As lower-income countries respond to this rapidly rising cause of disability, it is critical that they avoid the waste that these misguided practices entail.’
She concludes that there is little research into the effectiveness of prevention. The only interventions shown to be effective for secondary prevention are exercise combined with education, and exercise alone.
Professor Foster highlights a number of unnecessary interventions used globally, including:
  • lumbar imaging, which means exposure to radiation
  • liberal use of imaging, which triggers additional medical care including specialist referral, surgery, interventional procedures and
  • potential absence from work 
She adds that the growing use of complex fusion procedures in patients older than 60 years, who are undergoing decompressive surgery for spinal stenosis, is concerning.
‘These fusion operations are three times more expensive than decompression alone,’ she says.
Responding to the papers, Steve Tolan, head of practice at the CSP, said: ‘This landmark series of articles must prompt some serious reflection among professionals and decision-makers to ensure that when people seek help, what they receive is effective, proportionate and above all, empowering. 
‘The CSP’s mythbusting initiative sought to debunk misconceptions and deliver information that people can use to rationalise and manage the pain that so many of us will experience at some point in our lives.’ Nadine E Foster et al Prevention and treatment of low back pain: evidence, challenges, and promising directions Lancet online 2018.  

Advice on using a pedometer can boost step count over the long term

Professional advice on how best to use a pedometer to boost daily step count seems to help sustain physical activity levels over the longer term, suggest two studies of middle aged and older adults.
The researchers tracked the subsequent physical activity levels of participants from two completed 12 month trials (PACE-UP and PACE-Lift) to see whether an increased step count was sustainable over the longer term.
For PACE-UP, 1,023 inactive 45 to 75-year-olds were all given a pedometer and an activity diary and randomly assigned to one of three groups: advice sessions with a nurse to help them walk more; an information leaflet on pedometer use; no guidance at all.
PACE-lift involved 298 60 to 75 year olds, half of whom were given advice by a nurse on how to be more active.
Three years later, those in the PACE-UP trial who had been given written or verbal advice, were still clocking up an extra 600 daily steps and 24 more minutes of moderate-to-vigorous physical activity every week than those who had not been given any guidance.
Similarly, four years later, PACE-Lift participants in receipt of professional advice were still doing 400 more steps a day and 33 more minutes of moderate-to-vigorous exercise a week than those who had not been told how to boost their step count.
‘To get any of the health benefits linked to being more active, such as a lowered risk of heart disease, stroke and type 2 diabetes, people need to be more active in the long term,’ explains lead study author Professor Christina Victor of Brunel University, London.
‘Here we have new evidence that shows short, simple advice about regularly using a pedometer, whether that means getting leaflets through the post, or speaking to a nurse, can increase physical activity three to four years later.’ Harris T et al. Physical activity levels in adults and older adults 3–4 years after pedometer-based walking interventions: Long-term follow-up of participants from two randomised controlled trials in UK primary care Plos Medicine 2017.

Comments and conclusions

  • Tai chi is as good if not better than aerobic exercise for relieving the chronic pain of fibromyalgia, indicates a comparative trial of 226 people with the condition. Although standard treatment for fibromyalgia, many patients find exercise difficult. The researchers call for a rethink on the most effecive exercise. The BMJ 2018 
  • Weight loss surgery may be linked to a near doubling in risk of developing inflammatory bowel disease, suggests a study of nearly 9,000 cases and more than 43,000 controls. The procedure may prompt changes in gut microbes added to which weight loss surgery patients tend to have higher rates of vitamin D and bile salt deficiencies. Alimentary Pharmacology & Therapeutics 2018
  • A US study has found that moderate-to-vigorous physical activity levels are just as low among older adults without osteoarthritis or knee pain, as they are among those with painful knee osteoarthritis. The findings should act as a ‘wake-up call’, say the researchers. Arthritis Care & Research 2018
Caroline White and Lynn Eaton

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