WHO releases back pain management guidelines

6 minute read

Some common treatments are among those not recommended for managing chronic low back pain.

The World Health Organization has released its first-ever guidelines for managing chronic low back pain in primary and community care settings, listing interventions that should and shouldn’t be used. 

Chronic primary low back pain, defined as pain persisting more than three months that is not due to an underlying disease or condition, is a major cause of disability globally, affecting individuals’ quality of life as well as incurring substantial costs to families, communities and health systems. 

A total of 37 interventions were considered, with 10 conditionally recommended. Treatments that got the nod included NSAIDs, cognitive behavioural therapy, some physical therapies and structured exercise programs.  

There were 14 conditionally recommended against, and they are not recommended for most people in most contexts. These included muscle relaxants, injectable local anaesthetics, assistive products such as braces, opioids, antidepressants and transcutaneous electrical nerve stimulation. 

There were no recommendations strongly in favour of or strongly against any interventions. 

A further 12 had no recommendation either way, having either equivocal evidence or not enough evidence to make a recommendation. The guideline development group said there was no evidence available for paracetamol, often recommended as a first line treatment, and were unable to make a recommendation on it. 

Finally, there was a ‘good practice statement’ – meaning that there was a large body of indirect evidence that is difficult to summarise but unequivocally demonstrates a net benefit – related to the use of mobility assistive products.  

Designed for use in primary and community care settings, the guideline doesn’t cover surgical interventions and other invasive procedures typically delivered in secondary or tertiary care settings. 

“To achieve universal health coverage, the issue of low back pain cannot be ignored, as it is the leading cause of disability globally,” said Dr Bruce Aylward, WHO Assistant Director-General, Universal Health Coverage, Life Course, in a media statement.  

“Countries can address this ubiquitous but often-overlooked challenge by incorporating key, achievable interventions, as they strengthen their approaches to primary health care.” 

Good practice statement 

Mobility assistive products such as walking aids, wheelchairs and pressure cushions should be offered subject to a person-based assessment of needs and abilities, as well as training for the patient on how to use it. 

Conditional recommendation in favour 

Structured and standardised education and/or advice aims to improve a patient’s understanding of the pain experience and/or guide self-management, with education emphasising the benefits of staying active and engaged in work and social activities particularly important. There was very low certainty of evidence in favour, though it should be used as part of a broader treatment plan. 

Structured exercise therapies or programs prescribed or planned by health practitioners included aerobic exercise, strength training, stretching, yoga, Pilates and Tai Chi. There was low certainty of evidence in favour, especially when tailored to the individual, supervised and for more than 20 hours total program time. 

Needling therapies, including acupuncture and other dry needling, conducted by suitably qualified practitioners, have a low certainty of evidence in favour, though benefits are short-term. 

Spinal manipulative therapy administered by practitioners trained to deliver it safely has a very low certainty of evidence in favour, though benefits are short term. 

There’s very low certainty evidence that massage offers short-term improvements, though there may be an immediate increase in pain. When treating older people, the evidence is less clear, and practitioners should balance the potential benefits versus risk of harm. 

Among the psychological therapies, operant therapy – replacing pain-related behaviours with helpful, healthy behaviours – and cognitive behavioural therapy were recommended as part of a broader suite of effective treatments, based on very low certainty evidence. 

NSAIDs can be used as a short-term or as an intermittent treatment option as part of a broader suite of effective treatments, based on moderate certainty evidence. 

Of the herbal medicines considered, only topical Cayenne pepper received a conditional recommendation as part of a broader suite of treatments. 

There was a conditional recommendation in favour of multicomponent biopsychosocial care covering at least two components of biological (such as exercise programs), psychological (such as coping with pain) or social care (participation in work and social life), delivered by a single provider or multidisciplinary team. 

Conditional recommendation against 

Among the passive physical therapies, traction (using devices or body weight), therapeutic ultrasound and transcutaneous electrical nerve stimulation should not be used as part of routine care. For these modalities there was no evidence of meaningful benefit, and while there is potential for harm using traction, it wasn’t reported on in studies. 

Assistive products such as lumbar braces, belts and/or supports should not be used in routine care and could be associated with harms such as dependence, fear-based movement avoidance and deconditioning. 

While “probably” offering small improvements in pain and function, opioid analgesics should not be used as part of routine care for chronic low back pain due to the potentially serious adverse events such as dependence and overdose.  

Antidepressants (selective and noradrenaline reuptake inhibitors and tricyclics), anticonvulsants, skeletal muscle relaxants, systemic glucocorticoids and injectable local anaesthetics were recommended against due to the risk of harms outweighing small or trivial potential benefits. 

Devil’s claw and white willow were recommended against on the basis of small benefits and unknown harms.  

Pharmacological weight loss should not be used as part of routine care for low back pain, based on very low certainty of evidence for benefit and potential for harms (inadequate monitoring and follow-up were also noted). 

No recommendation – evidence equivocal, inadequate or non-existent  

Respondent therapy (reducing muscular tension), cognitive therapy (changing thinking around pain and disability) and mindfulness-based stress reduction training were psychological therapies with evidence so equivocal that a recommendation couldn’t be made. 

Likewise, evidence for non-pharmacological weight loss to manage back pain was so equivocal a recommendation couldn’t be made. 

No trials evaluated the benefits or harms of paracetamol, benzodiazepines or cannabis products in the management of chronic low back pain and the panel did not make recommendations for these medicines. 

There was only one trial found for each of topical Brazilian arnica, ginger and topical white lily, which was considered insufficient evidence to provide a recommendation.  

You can read the full guideline here

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