Low Back Pain: It's Time for a Different Approach

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Abstract
In spite of great effort, low back pain (LBP) remains a significant burden on society and one of the most common reasons to see a primary care provider. The conventional medical message about acute LBP is inconsistent with its actual clinical course. There is little agreement on the cause or best treatment. Back pain is "over-medicalized." Routine care is fragmented and episodic. We propose shifting to a practical, stratified approach based on rapid clinical recognition of mechanical syndromes with early identification of psychosocial issues and potentially serious pathologies. LBP is a chronic condition; the goal is control, not cure.
Key words: low back pain, LBP, natural history, medicalization, psychosocial issues, routine back care.

Low back pain (LBP) is one of the most prevalent and costly complaints in North America.1 It is among the most common medical reasons to see a family physician and is an enormous burden to society in general and the delivery of health care in particular.2,3 Whether it is the failure of our current medical paradigm, the widely accepted misconceptions, or misguided policies of third-party payers, the fact remains that unlike many other debilitating conditions and despite great efforts, the problem of LBP continues to grow.3,4 Many patients suffer brief, self-limiting episodes of LBP, but these are not the challenge.5,6 It is persistent or recurrent LBP that strains the system, disrupts society, and adversely impacts the individual. Just 25% of patients with LBP generate 75% of the financial and social costs.7

To better manage these complex patients, we need to distinguish several key aspects of LBP. First, the conventional medical message about acute LBP is inconsistent with its actual presentation.8,9 The current guidelines are correct that LBP is a benign condition with a favourable natural history, but this statement is often misinterpreted by patients and providers to mean that every attack will end quickly and all will be well.5 The majority of patients with a favourable course do not seek care from a physician.6 Growing evidence demonstrates that for patients requiring help, the symptoms are likely to return and, in a number of patients, to become chronic.8 Although this is acknowledged in many guidelines, it is not emphasized and no guideline adequately addresses how to deal with the fear and uncertainty of persistent or repeated LBP.5 Not unreasonably, for the patient who has been told, "Don't worry, it will get better," and for the physician who has followed the initial recommendation of current guidelines, continuing or recurring symptoms raise the spectre of an ominous pathology or serious illness.

Second, there is little agreement on the source of pain or the best management for a large number of sufferers of LBP, particularly those who have dominant back pain with minor leg symptoms and no neurological findings.10 The unhelpful and misleading term non-specific low back pain leads to the initial treatment of acute LBP as a homogeneous entity using simple, standardized, "one size fits all" routines that are frequently ineffective.5,10 LBP is a heterogeneous affair, and all current research points to significantly better outcomes with a more specific and stratified clinical approach.11,12 Although there is no uniform agreement as to the best non-surgical management, it is agreed that doing something active is better than adopting a passive, dependent approach.13

This heterogeneity leads to a third problem, the "medicalization" of LBP.4 Medical training and societal expectations dictate that we must establish a cause for the pain and base our therapy on a recognized pathology. This makes sense for diseases for which there are reliable means of diagnosis and an associated remedy. But most