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Lancet. 2018 Jun 9;391(10137):2368-2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21.

Prevention and treatment of low back pain: evidence, challenges, and promising directions.

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Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK. Electronic address:
Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands.
Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA.
Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.
Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia.
Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA.
Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands.
Department of Neurosurgery, Leiden University, Leiden, Netherlands.
Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA.
Sydney School of Public Health, University of Sydney, NSW, Australia.


Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

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