New WHO guidance on lower back pain advises against TENS, lumbar support

Key takeaways:

• WHO’s guidance on treating chronic lower back pain in primary care mostly affirms current practices.
• However, the agency advised against some common treatments like traction and lumbar support.

WHO recently released recommendations on managing chronic low back pain in primary care — the organization’s first ever guidelines on the subject.

According to WHO, a combination of techniques is needed to provide holistic chronic low back care.

“Primary care physicians are crucial in medicine as they provide the frontline care for patients. However, many are overwhelmed right now given the shortage of PCPs and the ever-increasing administrative burden being placed on them,” Jennifer Kendall, DO, an osteopathic physician specializing in physical medicine and rehabilitation, told Healio. “This can make it difficult for patients to establish with a PCP and can delay care for patients seeking treatment for their low back pain.”

Low back pain (LBP), the world’s leading cause of disability, affected roughly one in 13 people in 2020 — about 619 million, according to a press release from WHO. The data indicate that this is a rising problem; the release noted this rate is up 60% from 1990.

“Given that chronic LBP is such a prevalent problem worldwide, affecting millions of people, having guidance for care is very important,” Kendall said.

The recommendations

WHO’s guidelines focus on holistic and patient-centered care, equity and integrated care that should be individualized to address the unique combination of social, psychological and physical factors that could influence their experience. According to the release, “a suite of interventions may be needed to holistically address” a patient’s needs.

The guidelines primarily recommend nonsurgical interventions such as physical therapies like massage or spinal manipulative therapy, psychological therapies, exercise programs, medicines and education programs supporting general knowledge and self-care techniques. However, most of the evidence that was used in making these recommendations was low certainty.

“The guidelines recommending education and exercise programs are expected as these are typically the first-line treatments being offered to patients with chronic LBP,” Kendall said.

The guidance also recommends against 14 interventions that WHO decided should not be used for most people in most contexts because their evaluation indicated that the possible harms outweigh the benefits. They advised against:

• some physical therapies like traction;
• therapeutic ultrasound;
• transcutaneous electrical nerve stimulation, more commonly known as TENS;
• lumbar bets, braces and/or supports;
• pharmacological weight loss; and
• medication like opioid analgesics, antidepressants, anticonvulsants, skeletal muscle relaxants and glucocorticoids.

“These guidelines provide a reference for physicians as they recommend treatments for patients,” Kendall said. “However, these guidelines may decrease physician confidence in their treatment recommendations given that many recommendations in these guidelines are conditional due to low evidence. This is despite the fact that many of the options listed are considered standard treatments for chronic LBP.”

Clinical relevance

Kendall said many PCPs “are already treating patients with chronic LPB according to the recommendations in the guidelines,” so “it is unclear how impactful these guidelines will be.”

“The low evidence for many of the treatments listed highlights the need for further studies to guide future recommendations,” Kendall said.

Alan Dow, MD, MSHA, FACP, the Ruth and Seymour Perlin Professor of Medicine and Health Administration at Virginia Commonwealth University in Richmond, Virginia, agreed. He said the guidelines “generally mirror similar existing recommendations and the most common practices” he sees.

“I think this guidance is fine to review, but it does not add a lot to the field. For example, the American College of Physicians released a similar guideline in 2017,” Dow, who is also a Healio Primary Care Peer Perspective Board member, said. “There are some slight differences between the guidelines’ recommendations and what is examined, but overall, the changes are minimal and probably not highly important clinically. ... They recommend against some low-value but occasionally used therapies like TENS units and lumbar supports. This may be helpful.”

Dow said he had expected the guidelines to address the prevention of chronic LBP, and that “this public health aspect of back pain would seem to be more consistent with the typical work of the WHO.”

“I was also surprised that the increasing impact of obesity and lower levels of fitness was not more front-and-center as a concern for the possibility of increasing frequency of chronic LBP in the future,” Dow said. “One thing the guideline does demonstrate is the lack of comparative trials for prevention and treatment of chronic LBP. For a remarkably prevalent problem, we have a limited amount of evidence to guide the best approach among a number of options.”

Kendall also noted that adhering strictly to the guidelines means “there would be no recommended medication option for many patients with chronic LPB.”

“It should be noted that guidelines are recommendations and that physicians can use their personal judgment to treat their patients’ in their individual and specific situations,” she said. “In certain patients, lumbar supports/braces can be quite helpful, typically when just used for short periods of time. Certain subsets of patients can also respond quite well to lumbar traction.”

However, when PCPs feel out of their depth, Kendall said “they can rely on LBP specialists to partner with them to care for these patients.”

“There are nonsurgical spine specialists and there are surgical spine specialists who both can help manage chronic LBP,” Kendall said. “It is important for PCPs to consider first referring to nonsurgical spine specialists, as these specialists can manage long-term conservative treatment and refer to a surgeon if and/or when appropriate.”

References:

• WHO guideline on non-surgical management of chronic primary low back pain in adults. https://iris.who.int/bitstream/handle/10665/374726/9789240081789-eng.pdf. Published Dec. 7, 2023. Accessed Dec. 12, 2023.
• WHO releases guidelines on chronic low back pain. https://www.who.int/news/item/07-12-2023-who-releases-guidelines-on-chronic-low-back-pain. Published Dec. 7, 2023. Accessed Dec. 12, 2023.