World Health Organization Releases Chronic Back Pain Care Guidelines

December 7, 2023December 7, 2023 / Thomas Cohn, MD

Earlier this week, the World Health Organization (WHO) released its first-ever guidelines for managing chronic low back pain in primary and community care settings. Not only do the guidelines focus on what healthcare workers should be doing to help patients treat their back pain, they also outlined what techniques should be avoided during routine care.

The WHO felt compelled to issue these new guidelines because low back pain is the leading cause of disability in the world. In 2020, roughly 1 in 13 people experienced low back pain, which equates to 619 million people globally. This number also reflects a 60 percent increase from 1990, and cases of low back pain are expected to surge to 843 million by 2050.

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

WHO Chronic Low Back Pain Recommendations

The World Health Organization recommends non-surgical interventions to help patients experiencing chronic low back pain. They grouped their recommendations under different categories, which we’ll explore below:

Education – Patient education should be structured based on the individual needs of the patient and help the patient better understand their condition and some self-help strategies for treatment.

Physical Interventions – Physical intervention recommendations include structured exercise programs, physical therapy, spinal manipulation therapy, massage therapy, needling therapies and assistive devices.

Psychological Interventions – Operant therapy and cognitive behavioral therapy are recommended as treatments to address the psychological effects of chronic low back pain.

Medicines – WHO recommends non-steroidal anti-inflammatory drugs as part of a routine and comprehensive treatment plan for chronic low back pain.

Multi-Component Interventions – Finally, WHO recommends multi-component biopsychosocial care for patients battling chronic low back pain.

Interventions That Should Be Avoided

According to the World Health Organization, the following treatments should not be recommended as part of routine care for chronic low back pain. They may be recommended if specific conditions are met, but they are not currently recommended as part of routine chronic low back pain treatment:

Traction
Therapeutic ultrasound
TENS stimulation
Lumbar braces/Support belts
Opioid analgesics
SNRI antidepressants
Tricyclic antidepressants
Anticonvulsants
Skeletal muscle relaxants
Glucocorticoids
Injectable local anesthetics
Devil’s claw (Harpagophytum procumbens)
While willow (Salix spp.)
Pharmacological weight loss products

The recommendations by WHO mirror what we’ve been saying to patients for years. Chronic low back pain is best treated with active interventions like exercise and physical therapy, but it also needs to focus on patient education and the psychological effects of chronic pain. Treatment needs to be multi-faceted to be effective, so it’s nice to see that WHO is confirming the methods we’ve been using to help patients overcome their chronic low back pain for years.

If you need help treating low back pain or another chronic pain issue, reach out to Dr. Cohn and his team today at (952) 738-4580.

Understanding Nonspecific Low Back Pain

December 12, 2016January 25, 2017 / Thomas Cohn, MD

A recent reading in a new issue of one of the many medical journals that showed up at my home was an article on the management and treatment of low back pain for general practitioners. Usually I hope to pick up an interesting piece of knowledge to add to my treatment regimen, but unfortunately this article was a major disappointment. The focus of this article was on “nonspecific” low back pain. For a person with low back pain, this is the category of everyone who does not need surgery right away since they do not have a huge disc herniation.

Low Back Pain

Low back pain does have many specific causes and detailing the problem leads the practitioner to treatments that may be more effective. It is very important to understand that there are many structures in the low back region that can cause pain. Oftentimes multiple structures may be causing problems and treatment may need to include a number of different things. Solving only one of five problems leaves four issues that may be equal or worse and provide no relief for a patient.

To successfully treat low back pain, a practitioner must fully understand all the structures in the body and how they can contribute to pain. There multiple body parts involved including joints, nerves, discs, muscles, ligaments, bursas, and various organs in the lower abdomen and pelvis that all can contribute to pain sensations. On top of all the stuff in the direct area, the brain also can be an important factor since it is necessary to interpret the sensory signals and their meaning. If there are numerous sensory signals, the brain can short circuit on them and overly amplify the quality of pain. At this point, central sensitization occurs and normal sensory signals in the body can become interpreted as pain; the equivalent of a short circuit is present in the nervous system.

When low back pain is not easily fixed with time, simple medication and exercise, then getting higher level expertise with an expert in Physical Medicine doctor is helpful. Pain experts come in all varieties, but you should stick to those who have the broadest knowledge, since they will be more likely to be able to determine what is actually the problem and develop potential solutions. Many people claim to treat back problems, but only those who take the time to look into your history, to fully look at what has been done as far as diagnostic studies, and to conduct a physical exam will be successful.

The Pain Management Approach

Pain that has not been solved quickly is often a complex problem. Before I see a patient, I try to review their medical history and what has been done for diagnosis and treatment. A patient’s history and story about their problems often is the most important key to understanding what to do for a person. After hearing what the patient thinks is the problem, then a physical exam can often lead to a series of diagnoses. Most of the time, a person can tell me some odd information that is the absolute clue to helping a person with their pain problem. Tailoring the right treatment to a person is where experience is extremely helpful and what determines a successful management strategy. Many people are afraid that they are wasting the doctor’s time. Rarely if ever is a patient wasting my time, especially if they want to get better and are willing to try various treatments.

The human body is a wonderfully complex machine, and answering the question of what is wrong is very hard. Since in the low back, many things can be wrong, simple answers are rare. As people get older, everything in our bodies does deteriorate and degenerate. Some things in the body can be repaired, but many things like the discs and joints in the body show normal degeneration, sometimes by the age 30 or 40. Currently we have no way to reverse aging, and treatment of pain requires managing of symptoms. There often is no way to “fix” the problem, but we can find strategies to manage the symptoms better.

Safety First: Surgical Centers vs. Pain Specialists

January 19, 2015January 16, 2015 / Thomas Cohn, MD

Recently there was an article on whether having a procedure done in a surgery center is safe. In the world of pain management, some practitioners only do procedures in these facilities (or hospitals) while others do most of their procedures in the office. Surgery centers can handle more complex procedures, and can typically handle a deeper level of sedation. In pain management, surgery centers can be beneficial for complex procedures such as implants, but often they rarely are necessary. Sedation for a pain management procedure usually does not need to be very deep, and should be able to be done without a surgery center.

The safety of a surgery center and a procedure in reality is no better than the quality, skill, and experience of the practitioner. After spending more than 20 years performing complex spinal procedures, as well as teaching courses to other physicians, it is the ability of the physician that really matters. Surgery centers are often profit centers for the physicians working in them. Furthermore, a physician who sedates most patients for procedures is often using the sedation to cover for a technique that may cause pain. A skilled interventionist should be able to do most procedures with a local anesthetic and ensure they are practically painless. The use of sedation for many practitioners is a crutch to reduce the need to talk to the patient and to perform the procedure with the least painful technique.

Pain Medicine Safety

In pain medicine, the most common injections – spinal and joint related procedures – should be able to be done quickly and comfortably. The main issue that most practitioners should be treating is the anxiety of the patient. Light medication to treat the anxiety can often be given orally. For longer procedures, IV medication is sometimes easier to use. Universally, procedures that are painful are most often due to the technique and experience of the provider. Experience often allows the practitioner the knowledge of how to perform a procedure when a patient presents a more complex situation.

In the end, safety of a center is dependent on the practitioners. If the provider does not fully know what they are doing or the best techniques, the patient is more likely to have issues with the procedure. Further, if the patient is significantly sedated, the patient will not react when the practitioner does something wrong, making it more likely that significant damage may occur. The best physicians will always care most about the patient and the problem, not the payment they might receive from doing an intervention. The best physicians have years of experience, are board certified, and have an intense, loyal patient following. Skill and experience help keep a patient safe and make a procedure safe and effective. Errors in pain management procedures are generally rare. Surgical centers and sedation are not important in patient safety; the quality of the practitioner is the most important variable.

Lumbar Sprains & Low Back Pain: Treatment Options

November 11, 2013June 24, 2014 / Thomas Cohn, MD

Lumbar sprains are often considered a generic term to explain low back pain that originates from the muscles or ligaments. It is usually just in the low back and buttock area, and does not spread into the legs. Lumbar strains and sprains are not serious injuries, they do not involve damage to lumbar discs, lumbar nerves, the vertebrae, or joints. Pain is localized to the back and will resolve with conservative treatment.

What is a Lumbar Sprain?

Technically, sprains are tears of ligaments. In the lumbar area, these ligaments hold the bones in alignment with the help of muscles. Strains occur to muscles when they are overstretched. Most lumbar pain is related to injuries to the muscles, and thus are more correctly considered strains.

Mobility of the lumbar region is dependent on the action of both very large and very small muscles along the spine. The lumbar spine can bend forward and back, rotate and twist. Lifting and twisting can put excessive forces through the spine and muscles causing a strain. Pain usually appears after doing any of the following:

Performing too much lifting
Staying in a bent position
Performing repetitive lifting and twisting

Performing activities without the proper body mechanics, obesity, and poor conditioning are all contributing factors.

Treatment Options

Treatment of lumbar strains is typically conservative. Ice initially for a day or two and then heat is often helpful. Ice reduces initial swelling and pain, while heat facilitates muscle rest, blood flow, and healing. Nonprescription medications including anti-inflammatories like ibuprofen and aspirin as well as analgesics like acetaminophen are helpful. Rest should be limited to no more than two days. Over 90% of these will resolve readily in less than a month. Chiropractic therapy, massage, and physical therapy may all help improve function and diminish pain.

Full medical evaluation may be necessary if the pain continues longer than several weeks, or there are more serious problems like:

actual leg weakness,
numbness,
loss of control of the bowels or bladder,

Rarely will an injury to the spine, discs or nerves be present. Even in cases of more severe back injuries, most of these also heal with conservative care. Only in cases of neurologic compromise causing leg weakness or loss of control of the bowel or bladder would surgery be a definite consideration.

Low back pain is usually due to a muscle strain. Learning proper body mechanics and maintaining good core strength helps prevent injury. Almost everyone strains his or her back at some point. Conservative care and time will heal almost everyone.

Are X-Rays, MRIs, & CT Scans Helpful in Treating Back Pain?

August 5, 2013September 27, 2016 / Thomas Cohn, MD

One of the most common concerns of someone with low back pain is whether they need X-Rays or special scans such as a CT or MRI study. Usually, the answer is no. Most low back pain will resolve in weeks to a month or two with conservative care. For normal back conditions, imaging is not necessary to guide care and is needed only in a few circumstances. In this article, we will outline the three major imaging methods (X-Rays, MRIs, CTs) and discuss when each is recommended.

X-Rays

Plain X-rays of the lumbar spine can show all of the following:

Alignment and curvature
Disc space
Bones

X –rays are helpful when there is acute trauma to the spine and fractures are a concern. In children, where scoliosis is suspected, plain films of the spine are also helpful. In normal adults without the above 2 conditions, X-rays show very little information that is useful in managing low back pain. Chiropractic films of curvature do not contribute to management decisions in back pain, and just expose one to unnecessary radiation.

MRI Scans

MRI scans of the lumbar spine can give good detailed information with regards to the following:

Bones
Discs
Ligaments
Nerves
Other abnormalities in this region

In reality, MRI scans are best for determining surgical or advanced conservative pain intervention. If you have had a scan in the past, you probably wouldn’t need another one unless your physician suspects significant new changes such as cancer.

CT Scans

CT scans of the lumbar spine are very good at evaluating the bone structures, but are not as good when evaluating discs, muscles, and nerves. They are used in cases of trauma, since a scan can be done quickly, in minutes. CT scans are also used after surgery, or when the patient has implants that are not compatible with the magnets of an MRI scan. These scans are also done only when significant changes are suspected and a surgery type intervention is being considered.

Rarely is imaging absolutely necessary in the management of low back pain. Most low back pain heals rapidly with conservative treatment. If the low back pain is not improving, then one should find a Physical Medicine and Rehabilitation specialist.