Athletes with lower back pain need evidence-based treatments, study tells clinicians

Dr Thornton and her colleagues portray LBP as being a common problem plaguing sport. They suggest it can have a negative impact on athletes’ performance – and even contribute to them retiring at a relatively early stage.

They paint a stark picture of what is currently available to clinicians, noting: ‘There are no evidence-based or consensus-based guidelines for treating LBP in athletes.

‘Outside of sport, clinical practice guidelines recommend education, self-management, and physical and psychological therapies for most people with LBP.’

‘Whatever it takes’

Athletes, the authors suggest, are ‘performance-focused’ individuals who are ‘often willing to do whatever it takes, even sacrificing their health, to win’.

‘This dedication can mean athletes are vulnerable to making uninformed choices about their care and/or full symptom resolution before returning to sport may be expected.’

Athletes are performance-focused individuals who are often willing to do whatever it takes, even sacrificing their health, to win

Typically, athletes are offered a biomedical approach – focusing on imaging, passive therapies, pharmacological treatments, spinal injections and surgical interventions.

But, the authors warn, these options are associated with ‘high costs, insufficient evidence of effectiveness and potential increase in disability’.

Their attempts to answer this question were hampered by the paucity of randomised controlled trials (RCTs) that evaluate the effectiveness of the interventions commonly used in practice. They also found:

•      the few trials that have been conducted are generally of poor quality and have many biases
•      exercise – the most frequently evaluated intervention – was generally associated with reduced pain and improved function in athletes, but there were no       data on returning to sport
•      whether some types of exercise are more beneficial than others is unclear, and exercise interventions were frequently not clearly defined or described
•      no RCTs have investigated the use of spinal injections or surgery to manage athletes’ LBP

Is International Olympic Committee guidance being followed?

Summarising the International Olympic Committee's (IOC) guidance on tackling pain in elite athletes, the authors say this calls for the ‘contributors to pain’ to be addressed. Clinicians are also advised by the IOC to ‘employ therapies providing maximum benefit and minimal harm’, they note.

‘However, it is unclear if current management of LBP in sport aligns with these recommendations. Understanding what constitutes best practice for managing LBP in sport will help athletes and clinicians make informed decisions.’

Key question

The key question the authors posed in undertaking their systematic review was: ‘What is the evidence for common non-pharmacological treatments for managing LBP in athletes?’ They focused on 14 relevant RCTs in their study: the first to explore evidence for all types of treatment in this area in a systematic way, they claim.

It emerged that none of the trails featured the option of advising people to remain active, along with giving education and self-management. Yet these approaches are considered first-line strategies in the treatment of LBP in the general population, the authors note.

Cognitive-behavioural therapy – also seen as first-line treatment for chronic LBP in the general population – was not mentioned or investigated. ‘Current treatment of LBP in sport does not appear to align with the recommendations outlined within the IOC Consensus statement on pain,’ the paper states.

'High-quality' research vital

In their conclusion, the authors note: ‘High-quality RCTs are urgently needed to determine the effectiveness of common interventions for managing LBP in athletes.

‘Until such trials are completed, management of LBP in athletes should follow recommendations from evidence-based guidelines for the general population.’

To see the full version of Treating low back pain in athletes: a systematic review with meta-analysis, visit: http://dx.doi.org/10.1136/bjsports-2020-102723