Bed rest used to be the advice given to those with lower back pain, but now we know that the sooner someone can get moving again, the better. Experts now tend not to recommend bed rest at all, since lying down for more than 48 hours may actually delay recovery, as the body stiffens and weakens.
With an ageing population, it is estimated that by 2050, there will be more than 800 million cases of lower back pain worldwide – a 36% increase from 2020. That number comes from research done at the University of Sydney, part of the Global Burden of Disease Study, drawing on data from more than 100 countries.
Professor Manuela Ferreira, of the University of Sydney-aligned Sydney Musculoskeletal Health, believes we have to improve our approach to lower back pain. “The spine was made to move,” she says. “The fact it has so many joints should tell us something. But there is still this belief that, if you have back pain, then bed rest is a good option when, in fact, research has shown the one factor that can prevent another episode of back pain is physical activity.
“The secret is to move in a way, and to the extent or duration, that you can tolerate. Even just moving around, rather than sitting the whole day, is helpful.”
Pain medications tend not to be much help for lower back pain. Paracetamol has been found to be no better than a placebo, and non-steroidal anti-inflammatories, such as ibuprofen, are only slightly more effective. “Back pain is a complex and multifactorial condition,” says Ferreira. “It’s not like a toothache; it’s really much more similar to cardiovascular disease in that it’s about healthy lifestyle behaviour. You need to take care of your body weight, stay active and stop smoking to prevent it.”
Smoking is a risk factor for back pain because it affects the circulation, reducing the flow of nutrients to joints and muscles. It also increases the risk of the brittle-bone disease osteoporosis.
Surgeries for back pain aren’t necessarily the answer. Although they do help in some cases, many patients are still left with pain. The incidence of failed back surgery is 10-40%, and many experts now believe it is done too frequently.
At the University of Sydney, the first placebo-controlled study for decompressive spinal surgery is under way. The procedure being investigated is a laminectomy, in which a portion of the vertebral bone is removed to ease pressure on the spinal cord or nerves. All of the participants will go through a surgery, but some will have the bone removed and others won’t.
“We’re also running a couple of trials looking at digital health for back pain,” says Ferreira. “Some people might need only reassurance and tips on how to manage their symptoms, so we’ll be sending semi-personalised text messages to lower-back-pain patients for 12 weeks to see if that decreases the rate that they seek medical care unnecessarily.”
Another intervention being trialled involves a short video to be played in doctors’ waiting rooms to educate people on back-pain prevention. There are also investigations to see if opioids can be used judiciously, so that the benefits outweigh the risk of addiction.
Back pain remains the leading cause of physical disability worldwide, and it can affect almost anyone. “There are work-related injuries associated with it. Heavy lifting, or lifting in awkward positions, increases the risk.
“But we also know that back pain affects kids and adolescents. And the peak prevalence is at around 80 years old.”
Older people are more likely to be severely incapacitated, with a loss of mobility and independence, so staying active within physical limitations is particularly important. Tai chi has been shown to be helpful, and Ferreira says even a short walk or gentle stretching session can provide benefits and speed recovery.
If you include all those who will have knee, hip and neck pain in 2050 in addition to the 800 million-plus cases of lower back pain, it adds up to a lot of chronic conditions, she says.
“We won’t have the healthcare workforce needed to deal with that, so we had better make sure we find the right and most efficient prevention strategies.”
