WHO’s chronic primary lower back pain guidelines: What every DC should know

In late 2023, the World Health Organization released guidelines providing evidence-based recommendations on nonsurgical interventions for adults with chronic primary lower back pain. 

According to the 2023 overview, low–back pain is the leading global cause of disability. As reported, about one in 13 people (close to 619 million) are estimated to have experienced low-back pain. The study found this was a 60% increase from 1990. That number is expected to rise to an estimated 843 million by 2050. 

This article summarizes critical points from the WHO guidelines that every DC should be aware of when developing pain management treatment plans for their own chronic primary lower back pain patients. 

What’s in the chronic primary lower back pain guidelines?

It’s important to note WHO’s guidelines for chronic lower back pain apply to those who have had chronic primary lower back pain for more than three months and whose pain was not due to any underlying disease or condition.  

As summarized by WHO assistant director-general Bruce Aylward, “To achieve universal health coverage, the issue of low–back pain cannot be ignored, as it is the leading cause of disability globally…. Countries can address this ubiquitous but often-overlooked challenge by incorporating key, achievable interventions as they strengthen their approaches to primary health care.” 

These proposed guidelines are meant for use by doctors, nurses and allied health workers such as DCs, occupational therapists, pharmacists, community health workers and public health programs with the intention to combat and prevent chronic primary lower back pain.  

Guidelines for nonsurgical interventions for chronic lower back pain

In the WHO guidelines, several interventions are recommended for DCs to help patients with lower back pain. These nonsurgical interventions are intended to be noninvasive ways for those already experiencing low-back pain to manage and mitigate pain. These methods can include  

• some physical therapies, such as spinal manipulative therapy and massage therapy,  
• education programs supporting self-care strategies and knowledge expansion, physiological therapies,such as cognitive behavioral therapy,
• exercise programs with low-back pain as a consideration and
• medicine, such as nonsteroidal anti-inflammatory options.  

Key principles for adults experiencing chronic primary lower back pain

Interventions for chronic primary lower back pain need to be: 

• Holistic and person-centric: The experience of pain happens within personal and social contexts that include culture, knowledge and beliefs, gender, age and more. These factors must be considered when selecting management strategies for chronic primary lower back pain.  
• Equitable: Care should be provided equitably regardless of ethnicity, area of residence, health literacy, socioeconomic status, gender or age.  
• Integrated and coordinated: Care should be integrated and coordinated across all levels with attention to comorbidities and social needs.  
• Non-stigmatizing and non-discriminatory: Care delivery and communication (including how low-back pain is communicated) should be non-stigmatizing, avoid jargon and not focus on disability or impairment.  

What not to do

The WHO guidelines outline 14 different interventions that, in most cases, it does not recommend for those with chronic primary lower back pain: 

1. Traction 
2. Therapeutic ultrasound 
3. Transcutaneous electrical nerve stimulation (TENS)
4. Lumbar braces, belts and supports
5. Opioid analgesics
6. Serotonin and noradrenalin reuptake inhibitor (SNRI) antidepressants
7. Devil’s claw
8. Tricyclic antidepressants 
9. Anticonvulsants
10. Skeletal muscle relaxants
11. Injectable local anesthetics 
12. Glucocorticoids 
13. Pharmacological weight loss  
14. White willow  

Final thoughts

Chronic primary lower back pain is a complex and widespread problem affecting millions of people worldwide; the WHO’s guidelines encourage clinicians to address this type of pain with natural, nonsurgical interventions whenever possible, and to approach each patient and their experience of pain with an individualized treatment plan that focuses on whole-person wellness. 

For further updates on research and guidelines surrounding chiropractic care and how you can incorporate them into your own practice, we recommend subscribing to Chiropractic Economics magazine.