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Cited by 1,345Musculoskeletal pain and rehabilitationSpine and Intervertebral Disc PathologyPain Management and Treatment

Low back pain

Open access
Knezevic, Nebojsa Nick, Candido, Kenneth D, Vlaeyen, Johan W S, Van Zundert, Jan, Cohen, Steven P·2021·The Lancet
DOI 10.1016/s0140-6736(21)00733-9
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Abstract

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

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  • Multiple biological, psychological, and social risk factors contribute to the persistence of somatic symptoms, either individually or in combination.

    “Multiple biological, psychological, and social risk factors contribute to the persistence of somatic symptoms”

    From Persistent physical symptoms: definition, genesis, and management (2024) · cites this paper as [49]

    The risk-factor panel (page not available in our copy) lists genetic, lifestyle, and psychosocial factors associated with progression from acute to chronic low back pain. The Conclusions endorse a biopsychosocial model of chronic pain. The source supports the claim for low back pain, but does not establish it for somatic symptoms generally. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The biopsychosocial model is currently the most recommended paradigm for treating and preventing non-specific back pain.

    “Currently, the biopsychosocial model is the most recommended paradigm for the treatment and prevention of NBP [54].”

    From Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis (2024) · cites this paper as [54]

    The Conclusions (page not specified) describe widespread acceptance of the biopsychosocial model, and the Abstract says it should be considered in interdisciplinary treatment plans. The Prevention section discusses psychosocial risk factors and multidimensional interventions, but the paper does not call the model the *most recommended* paradigm for treating and preventing non-specific back pain. (LLM, conf=0.87)

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Cites

Flagged first, then by citations

1 of the 145 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. [6]6. Mounce K. Back pain. Rheumatology 2002; 41: 1-5.
  2. [15]15. Jordan J, Konstantinou K, O'Dowd J. Herniated lumbar disc. BMJ Clin Evid 2011; 2011: 1118.
  3. [31]31. Vlaeyen JWS, Maher CG, Wiech K, et al. Low back pain. Nat Rev Dis Primers 2018; 4: 52.
  4. [68]68. Huang W, Han Z, Liu J, Yu L, Yu X. Risk factors for recurrent lumbar disc herniation: a systematic review and meta-analysis. Medicine 2016; 95: e2378.

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Related

Authors
Knezevic, N. N., Candido, K. D., Vlaeyen, J. W. S., Van Zundert, J., & Cohen, S. P.
Affiliations
  • University of Illinois Chicago (US)
  • Maastricht University (NL)
  • Johns Hopkins University (US)
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2021-07
Volume
398
Issue
10294
Pages
78-92
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(21)00733-9
OpenAlex
W4211136641
Cited by
1,345
References
145
Citations by year
2026: 274 · 2025: 380 · 2024: 317 · 2023: 239 · 2022: 113 · 2021: 22
FWCI
21.91
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet (publishedVersion, public-domain)
  • PubMed (publishedVersion)
  • Lirias (KU Leuven) (acceptedVersion)
  • Research Publications (Maastricht University) (submittedVersion, public-domain)
  • Lirias (submittedVersion, public-domain)
  • Research Publications (Maastricht University) (submittedVersion, other-oa)
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Keywords
low back pain, pain classification, biopsychosocial model, diagnostic imaging, diagnostic injection, epidural steroid injection, spinal cord stimulation, radiofrequency ablation, intervertebral disc degeneration, sacroiliac joint, facet joints, neuropathic pain, nociplastic pain, non-specific low back pain, pain prevention, interdisciplinary treatment, pharmacotherapy, physiotherapy, psychological intervention, spinal decompression, disc replacement, spinal fusion, treatment algorithm, comparative effectiveness
MeSH terms
Humans, Risk Factors, Low Back Pain

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