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PainMar 2, 2021

Clinicians lack guidance on preventing flare-ups in cases of lower back pain, researchers claim

Physiotherapists and other clinicians who want to prevent recurring incidents of low back pain (LBP) have little evidence to draw on because researchers have tended to focus on the wrong group of patients.

That is the message contained in an editorial – titled Recommendations for shaping the future of low back pain – which appears in the latest issue of the British Journal of Sports Medicine.


Photo Credit: Shutterstock
Patients need the skills to manage their own conditions and carry on working


Both authors have physiotherapy backgrounds

The article is written by two Sydney-based researchers with physiotherapy backgrounds: Giovanni Ferreira, from the University of Sydney’s Institute for Musculoskeletal Health, and Mark Hancock, a professor in physiotherapy.

Despite prevention supposedly being a ‘fundamental tenet’ of medicine, the authors argue prevention has been ‘largely ignored’ in LBP investigations. Because the focus has been on treating individuals who are currently experiencing an episode, ‘little guidance’ has emerged for clinicians to draw on, the authors suggest.

'Silence' surrounding LBP prevention

Clinical practice guidelines are largely silent on the issue of prevention of LBP, providing little guidance to clinicians [Giovanni Ferreira and Mark Hancock]

As evidence, they say a recent review of LBP prevention included 40 trials, while, by comparison, there are ‘several thousand’ trials evaluating treatments for LBP. ‘Clinical practice guidelines are largely silent on the issue of prevention of LBP, providing little guidance to clinicians,’ Dr Ferreira and Professor Hancock note.

‘It is now recognised that LBP is typically an episodic condition, with many people having a symptom trajectory that includes periods of recovery interspersed with frequent recurrences or ongoing low levels of pain with flare-ups.

‘Much of the LBP burden, therefore, results from recurrences and flare-ups. Given this, we believe that the rationale and evidence for a greater focus on secondary or tertiary prevention are overwhelming.’

Efficient approach is vital

It would be an inefficient use of resources, they argue, to focus on primary prevention strategies and doing so could have ‘unintended negative consequences’ by creating avenues for LBP overtreatment, for example.

‘On the other hand, preventing recurrences in people recovered from a previous episode (secondary prevention) and the progression and consequences of LBP such as flare-ups (tertiary prevention) are more efficient approaches to reduce the burden of LBP,’ the authors state.

Possible ways forward


  • researchers should investigate how to prevent flare-ups
  • individuals need the skills to manage their own conditions (without seeking care or taking time off from work)
  • a 2011 consensus definition on recurrence should be refined, raising the threshold of what constitutes a recurrence
  • too many exercise-based trials have been ‘resource intensive, not widely accessible, and lacked flexibility’ – which limits their applicability in ‘real life’ scenarios

Conclusion: 'codesign interventions with patients'

‘To optimise the likelihood of wide-scale implementation, prevention interventions should be codesigned with patients and clinicians and trials should include nested evaluations of acceptability and barriers to implementation,’ Dr Ferreira and Professor Hancock conclude.

‘Effective LBP prevention is critical in reducing the burden due to LBP. The recommendations in this article aim to shape future LBP prevention research, so it has the greatest value and limits research waste.’

To see the article in full, visit: http://dx.doi.org/10.1136/bjsports-2020-103744

Author: Ian A McMillan
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