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Cited by 2,398Musculoskeletal pain and rehabilitationSpine and Intervertebral Disc PathologyPregnancy-related medical research

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

Open access
Foster, Nadine E, Anema, Johannes R, Cherkin, Dan, Chou, Roger, Cohen, Steven P, Gross, Douglas P, Ferreira, Paulo H, Fritz, Julie M +35 more·2018·The Lancet
DOI 10.1016/s0140-6736(18)30489-6
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Abstract

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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  • Across pain conditions, when hypnosis was provided adjunctively to usual care, the 95% CIs of pooled effects included what is commonly seen as clinically meaningful pain reduction.

    “Across pain conditions, when hypnosis was provided adjunctively to usual care, the 95% CIs of pooled effects included what is commonly seen as clinically meaningful pain reduction (difference between groups of ≥10 points on a 101-point scale).37”

    From Adjunctive use of hypnosis for clinical pain: a systematic review and meta-analysis (2024) · cites this paper as [37]

    The Treatment section discusses psychological therapies for low back pain, but does not report pooled effects of hypnosis added to usual care. Searches for hypnosis and for the claimed 10-point threshold on a 101-point pain scale found no passage addressing those results in our copy. (LLM, conf=0.75)

    Experimental — accuracy not yet measured

  • For chronic back pain, recommendations are education, exercise and psychological therapies.

    “For chronic back pain, recommendations are education, exercise and psychological therapies.6–9”

    From Results of a feasibility randomised clinical trial on pain education for low back pain in Nepal: the Pain Education in Nepal-Low Back Pain (PEN-LBP) feasibility trial (2019) · cites this paper as [9]

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1 of the 130 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Chou R, Deyo R, Friedly J, et al. Noninvasive treatments for low back pain: comparative effectiveness review No 169. Rockville, MD: Agency for Healthcare Research and Quality, 2016.
  2. Fialho SC, de Castro GR, Zimmermann AF, et al. Musculoskeletal system assessment in an emergency room. Rev Bras Reumatol 2011; 51: 240-48.
  3. Fuhrmans V. Withdrawal treatment: a novel plan helps hospital wean itself off pricey tests. The Wall Street Journal (New York). Jan 12, 2007. 119

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Authors
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., Anema, J. R., Chou, R., Cohen, S. P., Menezes Costa, L., Croft, P., Ferreira, M., Ferreira, P. H., Fritz, J. M., Genevay, S., Gross, D. P., Hancock, M. J., Hoy, D., Karppinen, J., Koes, B. W., Kongsted, A., Louw, Q., Öberg, B., Peul, W. C., Pransky, G., Schoene, M., Sieper, J., Smeets, R. J., Turner, J. A., & Woolf, A.
Affiliations
  • Johns Hopkins University (US)
  • Arthritis Research UK (GB)
  • The University of Sydney (AU)
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2018-06
Volume
391
Issue
10137
Pages
2368-2383
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(18)30489-6
OpenAlex
W2791379829
Cited by
2,398
References
130
Citations by year
2026: 257 · 2025: 287 · 2024: 348 · 2023: 312 · 2022: 304 · 2021: 345 · 2020: 274 · 2019: 182 · 2018: 80 · 2016: 2
FWCI
25.66
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • The Lancet (publishedVersion)
  • PubMed (publishedVersion)
  • EUR Research Repository (Erasmus University Rotterdam) (publishedVersion)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion)
  • EUR Research Repository (Erasmus University Rotterdam) (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Leiden Repository (Leiden University) (submittedVersion)
  • Research Publications (Maastricht University) (submittedVersion, other-oa)
  • Pure Amsterdam UMC (submittedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
  • VU Research Portal (submittedVersion, other-oa)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Funders
  • Kaiser Permanente
  • University of Washington
  • Johns Hopkins University
  • Kaiser Permanente Washington Health Research Institute
  • University of Alberta
  • National Institute for Health and Care Research (NF-SI-0512-10103, RP-011-015, NF-SI-0616-10043, NF-SI-0515-10095, NIHR-RP-011-015)
  • University of Exeter
  • University of Warwick
  • Macquarie University
  • Universiteit Leiden
  • Monash University
  • Vrije Universiteit Amsterdam
  • Universiteit Maastricht
  • Universiteit Stellenbosch
  • Keele University
  • Oulun Yliopisto
  • Syddansk Universitet
  • Medical Research Council
  • National Health and Medical Research Council
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Pregnancy-related medical research
Keywords
low back pain, back pain prevention, back pain management, biopsychosocial model, non-pharmacological treatment, physical activity, self-management education, psychological intervention, chronic low back pain, knowledge-practice gap, overuse of imaging, opioid overuse, spinal surgery, spinal injections, work disability, care pathways, occupational health interventions, public health prevention, cost-effectiveness
MeSH terms
Analgesics, Opioid, Cost-Benefit Analysis, Diagnostic Imaging, Female, Humans, Male, United States, United States Public Health Service, Low Back Pain, Practice Guidelines as Topic, Chronic Pain, Pain Management

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