<p class="first" id="d15692683e239">Many clinical practice guidelines recommend similar
approaches for the assessment
and management of low back pain. Recommendations include use of a biopsychosocial
framework to guide management with initial non-pharmacological treatment, including
education that supports self-management and resumption of normal activities and exercise,
and psychological programmes for those with persistent symptoms. Guidelines recommend
prudent use of medication, imaging, and surgery. The recommendations are based on
trials almost exclusively from high-income countries, focused mainly on treatments
rather than on prevention, with limited data for cost-effectiveness. However, globally,
gaps between evidence and practice exist, with limited use of recommended first-line
treatments and inappropriately high use of imaging, rest, opioids, spinal injections,
and surgery. Doing more of the same will not reduce back-related disability or its
long-term consequences. The advances with the greatest potential are arguably those
that align practice with the evidence, reduce the focus on spinal abnormalities, and
ensure promotion of activity and function, including work participation. We have identified
effective, promising, or emerging solutions that could offer new directions, but that
need greater attention and further research to determine if they are appropriate for
large-scale implementation. These potential solutions include focused strategies to
implement best practice, the redesign of clinical pathways, integrated health and
occupational interventions to reduce work disability, changes in compensation and
disability claims policies, and public health and prevention strategies.
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