Low back pain is defined as pain localized between the 12th rib and the inferior gluteal folds. Most cases of acute low back pain are “mechanical” or nonspecific, and are characterized by tension, soreness, or stiffness in the low back area. Although the source of pain and other symptoms might be attributed to several structures in the back, including discs, facet joints, muscles, and connective tissue, the specific source is often not identifiable.
Worldwide, low back pain causes more disability, activity limitation, and work absenteeism than any other condition. An estimated 80% of adults experience an episode of acute low back pain at least once in their life. Most low back pain episodes improve with initial primary care management, and without further investigations or referral to specialists.
It is important to recognize that the decrease in function and mobility associated with acute low back pain has an impact on the social and economic contexts of people’s health, well-being, and life in general. Evidence shows that people of low socioeconomic status are more likely to receive medication (opioids and/or nonsteroidal anti-inflammatory drugs) to manage their acute low back pain than are people of high socioeconomic status. People of low socioeconomic status also have a higher risk of recurrent, persistent low back pain and an overall poorer prognosis. People with acute low back pain who live in low socioeconomic areas do not have the same access to care as those living in high socioeconomic areas, and are disadvantaged by their restricted access to health care services. Despite evidence that opioids are not a useful treatment for acute low back pain, back pain is the most common reason physicians prescribe opioids in family medicine and the emergency department.
In Canada, about 30% of adults have low back pain that recurs within 6 months, and 40% within 1 year of their first episode. Most people with low back pain can benefit from lifestyle modifications (such as physical activity) and additional interventions (such as pharmacological therapies, heat, manual therapy, and therapeutic exercise). Although the literature provides consistent recommendations for managing low back pain, there is poor uptake of these recommendations and a lack of consistency in the provision of educational materials and resources to patients with low back pain.
Evidence shows that 90% of low back pain is not caused by serious underlying injury or disease that requires MRIs, CT scans, medication, surgical referrals, or opioid prescriptions. Less than 5% of low back x-ray examinations reveal a finding associated with red flags, which include neurological disorders, infection, fracture, tumour, or inflammation. Medical imaging for low back pain is being used more often than necessary. Imaging of the lumbar spine accounts for about one-third of all MRI examinations, and the use of diagnostic imaging has grown more rapidly than almost any other type of Canadian health service. In Ontario, there is considerable regional variation in the use of diagnostic imaging for low back pain. The total cost for spinal imaging, including x-ray examination, CT scanning, and MRI, was estimated to be $40.4 million in 2001/2 and increased to $62.6 million in 2010/11—a 55% increase over 10 years.
There are many opportunities for improving low back pain care in Ontario. These include decreasing the progression from acute low back pain to chronic low back pain; ensuring timely access to education to help patients manage their symptoms; ensuring access to an appropriate health care provider when it is required; decreasing the use of inappropriate imaging for low back pain; and decreasing the use of opioids. Several programs aim to address these issues, although there is limited access to acute low back pain resources and marked geographic variation in access across the province.