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

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

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Foster, Nadine E, Anema, Johannes R, Cherkin, Dan, Chou, Roger, Cohen, Steven P, Gross, Douglas P, Ferreira, Paulo H, Fritz, Julie M, Koes, Bart W, Peul, Wilco, Turner, Judith A, Maher, Chris G, Buchbinder, Rachelle, Hartvigsen, Jan, Cherkin, Dan, Foster, Nadine E, Maher, Chris G, Underwood, Martin, van Tulder, Maurits, Anema, Johannes R, Chou, Roger, Cohen, Stephen P, Menezes Costa, Lucíola, Croft, Peter, Ferreira, Manuela, Ferreira, Paulo H, Fritz, Julie M, Genevay, Stéphane, Gross, Douglas P, Hancock, Mark J, Hoy, Damian, Karppinen, Jaro, Koes, Bart W, Kongsted, Alice, Louw, Quinette, Öberg, Birgitta, Peul, Wilco C, Pransky, Glenn, Schoene, Mark, Sieper, Joachim, Smeets, Rob J, Turner, Judith A, Woolf, Anthony·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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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: Cohen, Steven P
Buchbinder, Rachelle
Hartvigsen, Jan
Underwood, Martin
Croft, Peter
Ferreira, Manuela
Genevay, Stéphane
Hancock, Mark J
Karppinen, Jaro
Kongsted, Alice
Louw, Quinette
Öberg, Birgitta
Pransky, Glenn
Schoene, Mark
Sieper, Joachim
Smeets, Rob J
Woolf, Anthony
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
FWCI: 25.66
Type: journal article
Language: en
Open access: bronze
doi.org
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 › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Orthopedics and Sports Medicine › Spine and Intervertebral Disc Pathology
Health Sciences › Medicine › Obstetrics and Gynecology › 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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