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The high prevalence of low-back pain (LBP) has been highlighted for many years, but until recently, awareness of its influence on the population was inadequate. The results of the Global Burden of Disease (GBD) Projects 2010 have informed us that the leading cause of disability (as measured by years lived with disability) worldwide is low back pain.  Additionally, musculoskeletal conditions as a whole are the second greatest cause of disability globally according to a report by international experts, published in The Lancet on December 15th, 2012.  In the first comprehensive study of the worldwide impact of all diseases and risk factors, musculoskeletal (MSK) conditions such as arthritis and back pain affect over 1.7 billion people worldwide, and have the fourth greatest impact on the overall health of the world population, considering both death and disability.  This burden has increased by 45% over the last 20 years and will continue to do so unless action is taken.  This landmark study of the global burden of all diseases provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease.

With the knowledge that LBP is the number one cause of disability in the world, it is unfortunate that little is known about the detailed course, and trajectory, of LBP.  Until recently LBP was believed to be a self-limiting condition, similar to the common cold. However, research in the past two decades has shown that LBP is actually a recurrent condition that could be likened to a more chronic condition such as asthma.  In this regard, we are starting to look at LBP as not seen as a single entity, but rather to the LBP condition which can be regarded as a chain of LBP episodes.  So, we need to view LBP (and maybe all types of spine pain) as having a lifelong course – perhaps with different etiology and modifying factors as life progresses, but always existing as an underlying ‘trait’.

When researchers have looked at the non-benign, and non self-limiting nature of the condition, three large groups of LBP patients emerge: 1): those without LBP; 2) those who experience it on and off and; 3) those who have it most of the time. It is pretty clear that definite recovery with no recurrences does not appear to be common, although to date, we do not know how these patterns develop over the course of a lifetime. People with LBP will not necessarily seek care, but a person who consults a chiropractor for an episode of LBP is likely to feel better fairly quickly. In light of these findings, clinicians should observe and convey information about episodes within the context of a longer-term pain trajectory, to provide patients with a realistic view of the problem. The authors of the recent trajectories of low back pain article referenced herein suggest that effective short-term treatment strategies, pain management and activity maintenance as well as secondary and tertiary prevention should be high on the clinical agenda. ‘Management rather than cure’ might be a helpful catch phrase, similar to the well-known recommendation of ‘don’t worry – keep active’ (Axén and Leboeuf-Yde, 2013).

Given the shift in attention of LBP to view it as a chronic condition, researchers and clinicians are putting more emphasis on investigating LBP throughout the life course.  What is emerging from this life course investigation is that similar factors (e.g., genetics, parental factors, psychological factors, injury, physical activity, comorbidity) are associated with the pain at different times. There appears to be strong evidence for the links between back pain, pain at other locations (e.g., shoulder) and other health problems. This evidence leads to the potential conclusion that vulnerability for long-term back pain develops at an early age, likely in childhood, and influences the occurrence of, and recovery from, episodes of back pain (Dunn et al, 2013).

Furthermore, results of a recent meta-analysis of LBP in children and adolescents indicates higher prevalence rates of LBP in the most recent studies suggesting that this a problem that is increasing in this young population (Calvo-Muñoz et al, 2013). As a consequence, more attention should be devoted to develop and apply prevention programs and early detection programs for young children in order to reverse this tendency.

Key Points

  • The leading cause of disability worldwide is low back pain
  • Evidence is mounting that classifying low back pain as acute, subacute and chronic is no longer helpful
  • Many individuals experience multiple episodes of back pain with the first episode occurring early in life
  • LBP is now being thought of as a potentially chronic health condition in its own right

References:

1. Vos T et al.Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2163-96.

2.Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12.

3. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):591-600.

4. Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013 Jan 26;13:14.

Podcast

In this episode, Dr. Jeff Hebert discusses back pain in young people, the link between back pain, health behavior and cardiovascular disease & sport participation as a health intervention. Jeff Hebert, DC, PhD is a Professor and the CCRF/NBHRF Chair of Musculoskeletal Health Research at the University of New Brunswick, as well as an Adjunct Professor at Murdoch University in Australia. Jeff’s career to date includes 18 years of experience in faculty, clinical, and administrative positions in Canada, the United States, and Australia.  Most recently, he was the Associate Dean (Research) in Murdoch University’s School of Psychology and Exercise Science. Previous appointments include positions as a Senior Lecturer of Rehabilitation Science (Murdoch University) and Assistant Professor of Neurosurgery (University of Utah). He has earned a Bachelor’s degree in Psychology (University of Denver) as well as a Doctorate in Chiropractic (Palmer College) and PhD in Exercise Science (University of Utah). He serves as an Associate Editor for the journal Chiropractic & Manual Therapies. Before pursuing an academic career, Jeff worked as an outpatient and hospital-based clinician in multidisciplinary environments including as pain medicine, sports medicine, and spine surgery.

View Dr. Hebert’s research publications at researchgate.net.

Here are the articles that we discussed in this episode of the chiropractic science podcast.

1. Pubertal development and growth are prospectively associated with spinal pain in young people (CHAMPS study-DK).
  Hebert JJ, Leboeuf-Yde C, Franz C, Lardon A, Hestbæk L, Manson N, Wedderkopp N.
  Eur Spine J. 2019 Feb 11. doi: 10.1007/s00586-019-05905-6. [Epub ahead of print]
  PMID: 30740638 [PubMed – as supplied by publisher]
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2. The relationship of lumbar multifidus muscle morphology to previous, current, and future low back pain: a 9-year population-based prospective cohort study.
  Hebert JJ, Kjaer P, Fritz JM, Walker BF.
  Spine (Phila Pa 1976). 2014 Aug 1;39(17):1417-25. doi: 10.1097/BRS.0000000000000424.
  PMID: 24859576 [PubMed – indexed for MEDLINE]
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3. Physical activity is prospectively associated with spinal pain in children (CHAMPS Study-DK).
  Franz C, Møller NC, Korsholm L, Jespersen E, Hebert JJ, Wedderkopp N.
  Sci Rep. 2017 Sep 14;7(1):11598. doi: 10.1038/s41598-017-11762-4.
  PMID: 28912463 [PubMed – in process] Free PMC Article
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4. The Prospective Association of Organized Sports Participation With Cardiovascular Disease Risk in Children (the CHAMPS Study-DK).
  Hebert JJ, Klakk H, Møller NC, Grøntved A, Andersen LB, Wedderkopp N.
  Mayo Clin Proc. 2017 Jan;92(1):57-65. doi: 10.1016/j.mayocp.2016.08.013. Epub 2016 Nov 16.
  PMID: 27865444 [PubMed – indexed for MEDLINE]
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