Lancet. 2018 (Jun 9); 391 (10137): 2384–2388 ~ FULL TEXT
Rachelle Buchbinder, Maurits van Tulder, Birgitta Öberg, Lucíola Menezes Costa, Anthony Woolf, Mark Schoene, Peter Croft, on behalf of the Lancet Low Back Pain Series Working Group
Cabrini-Monash Department of Clinical Epidemiology,
Cabrini Institute and Monash University,
Malvern, VIC, Australia.
Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population.  Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series, [2, 3] is a call for action on this global problem of low back pain.
The FULL TEXT Article:
The Panel summarises the most pressing political, public
health, and health-care challenges and identifies actions
to meet them. Prevention of the onset and persistence of
disability associated with low back pain requires
recognition that the disability is inseparable from the
social and economic context of people’s lives and is
entwined with personal and cultural beliefs about back
pain.  Health and workplace policies and disability
payment systems are often ineffective and wasteful, and
they are key targets for improvements. Socioeconomically
disadvantaged people are over-represented among those
with disabling low back pain.  In many settings they will
be further disadvantaged by restricted access to accurate
information sources, health-care approaches that provide
appropriate support for self-management of uncomplicated
low back pain, and to specialised effective
interventions, such as multidisciplinary rehabilitation,
for complex persistent low back pain.
Call for actions to meet the challenges associated |
with prevention of disabling low back pain
Political challenge: increase recognition of the effects and burden of back pain
by international and national policy makers
Call on WHO to put disabling low back pain on the target list
for all nations and increase attention on the burden it causes,
the need to avoid excessively medical solutions, and the need
to integrate low back pain into all chronic disease initiatives
Call on international and national political, medical and
social policy leaders to adequately fund public health
strategies focused on preventing low back pain from
interfering with life, ensuring inclusion of disadvantaged
and culturally diverse populations
Call on national and international funding agencies to make
low back pain research a global health priority in recognition
of its impact on people’s lives in all countries
Public health challenge: prevent onset and persistence of disability
associated with low back pain
Prioritise low back pain, together with other
musculoskeletal conditions, as a public health problem
Develop and implement positive strategies for primary
prevention of disabling low back pain that are integrated with
strategies for preventing other chronic conditions (physical
activity, maintenance of healthy weight, mental health)
Develop and implement strategies to address modifiable
risk factors for disabling low back pain at all levels (society,
workplace, health professionals, individuals)
Change systems and change practice
Integrate back pain care with public health initiatives providing
credible advice that people who develop low back pain should
stay active and remain working, and that people with low back
pain should be supported in early return to work
Develop and implement strategies to ensure early
identification and adequate education of patients with low
back pain at risk for persistence of pain and disability
Promote a healthy lifestyle and address common
comorbidities in patients with persistent low back pain,
tackle social determinants of disability, incentivise work
through change and adaptation of the workplace and the
job, and change worker disability policies which do not
improve, promote, or support return to work
Consider provision of financial incentives to resume
appropriate work without risk of loss of benefits for people
who are off work because of low back pain
Promote active multidisciplinary rehabilitation to support
return to work
Health-care challenge: move away from emphasis on a biomedical and
fragmented model of care
Develop interventions to address misconceptions about low
back pain among health professionals, patients, the media,
and the general public
Promote the concept of living well with low back pain:
person-centred care focusing on self-management and
healthy lifestyles as a means of restoring and maintaining
function and optimising participation
Investigate the effectiveness and place of traditional
practices for reducing disability associated with low back
pain in low-income and middle-income countries
Change clinician behaviour
Invest in implementation research to address
evidence-practice gaps across all relevant health-care
Identify and implement effective behaviour change and
training interventions to improve and integrate care
Deliver a workforce fit-for-purpose, which includes targeted
training of health-care professionals and others with the right
competencies and resolve to deliver evidence-based care
Build consensus across clinical disciplines, patient groups,
and journal editors for shared guidelines of care that are
straightforward and non-denominational
Develop clear care pathways, referral, funding, and
information technology systems to enable people to see the
right person for delivery of the right treatment at the right
time, while precluding use of alternative inappropriate
Develop consistent evidence-based clinical care standards
and key indicators integrated across health-care systems
Develop and implement cost-effective strategies that
provide access to effective care in low-income and
middle-income countries for all
Tackle vested interests
Government, insurers, and commissioners should consider
tackling conflicts of interest through regulation and
contracts, including not paying for inappropriate tests and
for unnecessary, ineffective, and harmful treatments
Existing and new tests and procedures for low back pain
should be regulated in the same way as drugs; evidence
should be available showing that they are safe, effective,
and cost-effective before they get reimbursed within public
Introduce incentives for effective and efficient care and
disincentives for continued use of ineffective and potentially
Public health programmes that tackle obesity and low
levels of physical activity might provide a model and
structure for reducing the effects of low back pain on
daily life,  although independent associations between
the life-style issues and low back pain are uncertain.
Implementation of these programmes is especially
urgent in some low-income and middle-income countries
where increasing obesity rates and rapid industrial
growth and consequent reductions in physical activity
are occurring in urban areas. Health system and societal
initiatives addressing low back pain should act in synergy
with the WHO European Region action plan for the
prevention and control of non-communicable diseases,
which recognises the need for comprehensive promotion
of musculoskeletal health. Because low back pain
disability often affects employability in the informal
sector, integration between health, workplace, and social
services should also be a key goal.
Disabling low back pain is partly iatrogenic. Studies
in low-income countries and Indigenous and assimilated
populations in high-income countries show that
exposure to health care can sometimes have harmful
consequences. [7–9] Such negative effects of health care
reflect a change in views, from low back pain being
a fairly benign part of daily life, to it being seen as a
problem requiring medical attention. Increased use of
ineffective potentially unsafe treatments has wasted
limited health-care resources and harmed patients. The
epidemic of addiction and rising mortality resulting from
increased opioid prescribing in the USA over the past
20 years is a dramatic example of the disastrous effects
of damaging medical intervention.  In low-income
and middle-income countries, epidemiological evidence
suggests that improving social and economic conditions
could prevent or reduce incidence of low back pain,
but could also create expectations and demands for
medical investigations and low-value health care that
paradoxically increase the risk of long-term back-related
disability (what we term the low back pain paradox).
The global challenge is to prevent the use of practices
that are harmful or wasteful while ensuring equitable
access to effective and affordable health care for those who
need it. High rates of advice to rest and use of ineffective
treatments are already a reality in low-income and middle-income
countries. Over-medicalisation disproportionately
affects the wealthy minority, but it also threatens to reduce
availability of high-value health-care services for the poor
majority and further widen health and social disparities.
Contextual factors, such as scarcity of suitable work,
might also mean that advice that would be regarded
as appropriate in high-income countries, such as
encouragement to remain in work or return to work early,
might not always be appropriate — or even an option — in
low-income or middle-income countries.
Protection of the public from unproven or harmful
approaches to managing low back pain requires that
governments and health-care leaders tackle entrenched
and counterproductive reimbursement strategies, vested
interests, and financial and professional incentives that
maintain the status quo. Funders should pay only for
high-value care, stop funding ineffective or harmful tests
and treatments, and commission research into tests and
treatments without supporting evidence. As with drugs,
which are subject to strict regulation in many countries,
new diagnostic tests and non-drug treatments should be
available only in trials until their efficacy, safety, and cost-effectiveness
is established by robust research evidence.
Use the notion of positive health — the ability to adapt and to self-manage in the face of social, physical and emotional challenges — for the treatment of non-specific low back pain
Avoid harmful and useless treatments by adopting a framework similar to that used in drug regulation — ie, only include treatments in public reimbursement packages if evidence shows that they are safe, effective, and cost-effective
Address widespread misconceptions in the population and among health professionals about the causes, prognosis, and effectiveness of different treatments for low back pain, and deal fragmented and outdated models of care
Policy, public health, health-care practice, social services, and workplaces must jointly tackle the low back pain paradox in low-income and middle-income countries, where improving social and economic conditions could prevent or reduce low back pain incidence, but at the same time create expectations and demands for medical investigations and low-value health care that increase the risk of long-term back-related disability
Some countries are testing these approaches. In
Australia, a clinician-led taskforce is reviewing all
government-subsidised tests and procedures, with the
aim of removing funding for those that are unnecessary,
outdated, or potentially unsafe. In the Netherlands,
unproven interventions are conditionally included in the
public health insurance package only if there is evidence
from high quality randomised controlled trials to inform
a final decision that show whether or not the intervention
is efficacious and safe. Stakeholders, including patients,
agree to design and eligibility criteria for the assessment.
Because radiofrequency denervation for patients with
chronic low back pain does not provide clinically
significant added benefit compared with a standardised
exercise programme alone, it is no longer covered in the
public health insurance package. 
Awareness of the biopsychosocial model of low back
pain has greatly advanced the understanding of the
prognostic significance of psychosocial factors in
individual patients. The model has had less success in
shifting practitioners away from managing patients within
a biomedical framework. The importance of behavioural
approaches to back pain management does not preclude
the continuing need to investigate mechanisms and
potential biological determinants of non-specific low back
pain in phenotypically distinct subgroups.
We propose adoption of the so-called positive health
concept as the overarching strategic approach to the
prevention of long-term disability from low back pain. 
Positive health, as proposed by Huber and colleagues, is
“the ability to adapt and to self-manage, in the face of
social, physical, and emotional challenges”. This term
encompasses a much broader idea of health than simply
absence of disease and its emphasis on medicalisation
Evidence suggests that prevalence of long-term
disabling low back pain could be reduced by adopting
this positive health approach. [12, 14] For health professionals,
positive health focuses on alternatives to treatments and
cures and promotes high-quality, meaningful lives for
people with persistent low back pain. Public and patients’
expectations need to change, so that people are less likely
to expect a diagnosis or complete cure for their pain. This
adjustment of attitude requires initiatives to change
widespread and inaccurate beliefs about back pain, 
helping future generations to avoid counterproductive
patterns of illness behaviour, eg, prolonged rest,
avoidance of usual activities, or staying away from work.
For people with persistent low back pain, positive
health entails learning how to cope with a long-term
health problem through self-management activities, and
learning to seek health care only when needed. Passive
approaches such as rest and medication are linked with
worsening disability, whereas active strategies such as
exercise are associated with reduced disability and less
reliance on formal health care. Many behavioural and
cognitive strategies are used by people with chronic pain
in the community, regardless of whether or not they seek
care.  In the occupational setting, interventions focusing
on positive health, including peer support for the notion
that low back pain is not an injury in need of medical
treatment,  and redirecting problem-solving efforts away
from seeking cures and towards improved individual
adaptation to the pain, yield beneficial outcomes. 
Improved training and support of primary care doctors
and other professionals engaged in activity and lifestyle
facilitation, such as physiotherapists, chiropractors,
nurses, and community workers, could minimise the
use of unnecessary medical care. Crucial to changing
behaviour and improving delivery of effective care are
system changes that integrate and support health professionals
from diverse disciplines and care settings
to provide patients with consistent messages about
mechanisms, causes, prognosis and natural history of low
back pain, as well as the benefits of physical activity and
exercise. Traditional healers, where integrated into the
health-care system, community health workers, and family
remain important providers of lower cost basic education
and care in many low-income countries for most people
with low back pain who do not require medical attention. 
In rural and remote regions rehabilitation advice and
support given online, combined with self-management,
might be an option where internet access is available.
The success of a positive health approach will depend
on whether relevant stakeholders share the same
mission, vision, and objectives and on the success of
strategies for knowledge transfer and exchange. The
Appendix lists information that well informed consumers, patients, clinicians, and policy makers should know
about low back pain and its global burden.
Policy makers in all countries should look to local
stakeholders to help decide what overall strategies should
be put in place. Similar to other areas of research low-income
and middle-income countries should ensure that
investment in musculoskeletal services is effective for
patients and does not damage local health systems. 
Local participation and ownership, integration with
existing priorities and policies, and coordination with
national and regional systems and processes are crucial.
Funding for low back pain research is inadequate and
uncoordinated. This scarcity of funds especially affects
low-income and middle-income countries, where the
effects of disabling low back pain remain under-recognised
and research priorities and funding remain focused on
infectious diseases. One way forward would be to establish
a global network of researchers from developed and
developing countries, pooling experience and knowledge
and building research capacity where it is needed.
The Appendix lists major research priorities, which align
with those previously identified by the international low
back pain primary care research community.  Implementation
research is necessary in all countries to ascertain
how best to use existing knowledge and evidence through
changes in patient and clinician behaviour and health
system design. For low-income and middle-income
countries, priorities include identifying interventions that
are optimal in the context of the social, political, cultural,
and health-resource factors. Although available evidence-based
guidelines might be well suited for high-income
countries and highly developed health-care systems, they
might need adaptation to assure feasibility and cultural
appropriateness for low-resource settings.
An active ongoing monitoring system is crucial to
assess the effects of new strategies on outcomes such as
disability, ability to work, and social participation. There
is a pressing need for surveys and health-care databases
in different countries that use common metrics for
measuring the burden of low back pain, use of active self-management
strategies such as exercise, tests, and
treatments, and outcomes and costs of care. The Appendix shows a set of indicators of success for
surveillance. Uniform data collection would encourage
benchmarking of health services within and across
countries. Standardised definitions of low back pain for
prevalence studies have already been developed and
incorporated into the Global Alliance for Musculoskeletal
Health Surveillance Taskforce survey module for
Action is needed to address the growing burden of low
back pain on many millions of people worldwide. Future
social changes, including ageing, urbanisation, increasingly
sedentary lifestyles, and the development of new
technologies, will probably exacerbate this problem. For
example, the use of increasingly sensitive imaging
techniques, such as MRI, can reveal findings that might be
incorrectly inferred to be the cause of a patient’s symptoms.
Improved recognition of the growing burden of low back
pain is essential to stimulate new, more effective, strategies
of prevention and care. The effects of disabling low back
pain can be reduced through social change that supports
full participation in daily life. In low-income and middle-income
countries, the paradox of low back pain needs to be
addressed. Other barriers to optimal evidence-based
management include widespread misconceptions of the
general public and health professionals about the causes
and prognosis of low back pain and the effectiveness of
different treatments, fragmented and outdated models of
care, and the widespread use of ineffective and harmful
care, particularly in countries regarded as models of high
We have described actions all countries can take to
reduce the effect of disabling low back pain on their
populations. Strong and coordinated political action
from international and national policy makers, including
WHO and research funding agencies, is needed. Such
action could substantially reduce disability and suffering
and improve the effectiveness and efficiency of care for
people with low back pain throughout the world.
RB and MvT were part of the team that developed the original proposal
for the series and RB coordinated the development and amendment of
the paper. RB, MvT, BÖ, LMC, AW, MS, and PC all contributed to
drafting and writing of this paper, and have edited it for key content. RB,
LC, and PC drafted and analysed the survey of the Lancet Low Back Pain
Series Working Group that populated the draft version of the panels in
this paper. RB, MvT, BÖ, LMC, AW, and PC participated in the authors’
meeting and discussion during the drafting process. All other authors
have read and provided substantive intellectual comments on the draft
and approved the final version of the paper.
The Lancet Low Back Pain Series Working Group
Rachelle Buchbinder (Chair) Monash University, Melbourne, Australia;
Jan Hartvigsen (Deputy Chair), University of Southern Denmark, Odense, Denmark;
Dan Cherkin, Kaiser Permanente Washington Health Research Institute, Seattle, USA;
Nadine E Foster, Keele University, Keele, UK;
Chris G Maher, University of Sydney, Sydney, Australia;
Martin Underwood, Warwick University, Coventry, UK;
Maurits van Tulder, Vrije Universiteit, Amsterdam, Netherlands.
Johannes R Anema, VU University Medical Centre, Amsterdam, Netherlands;
Roger Chou, Oregon Health and Science University, Portland, USA;
Stephen P Cohen, Johns Hopkins School of Medicine, Baltimore, USA;
Lucíola Menezes Costa, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil;
Peter Croft, Keele University, Keele, UK;
Manuela Ferreira, Paulo H Ferreira, Damian Hoy, University of Sydney, Sydney, Australia;
Julie M Fritz, University of Utah, Salt Lake City, USA;
Stéphane Genevay, University Hospital of Geneva, Geneva, Switzerland;
Douglas P Gross, University of Alberta, Edmonton, Canada;
Mark Hancock, Macquarie University, Sydney, Australia;
Jaro Karppinen, University of Oulu and Oulu University Hospital, Oulu, Finland;
Bart W Koes, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands;
Alice Kongsted, University of Southern Denmark, Odense, Denmark;
Quinette Louw, Stellenbosch University, Tygerberg, South Africa;
Birgitta Öberg, Linkoping University, Linkoping, Sweden;
Wilco Peul, Leiden University, Leiden, Netherlands;
Glenn Pransky, University of Massachusetts Medical School, Worcester, USA;
Mark Schoene, The Back Letter, Lippincott Williams & Wilkins, Newburyport, USA;
Joachim Sieper, Charite, Berlin, Germany;
Rob Smeets, Maastricht University, Maastricht, Netherlands;
Judith A Turner, University of Washington School of Medicine, Seattle, USA;
Anthony Woolf, Royal Cornwall Hospital and University of Exeter Medical School, Truro, UK.
Declarations of interest are provided in the Appendix.
Declaration of interests
RB is chief investigator or associate investigator on multiple previous
and current research grants from government research agencies from
Australia (eg, NHMRC, ARC), and overseas (eg, ZonMW in the
Netherlands and PCORI in the USA). Her research has also received
funding from philanthropy (eg, Arthritis Australia) and government
agencies (eg, NSW WorkCover). She has been funded by research
fellowships from NHMRC since 2005. She has received travel expenses
for speaking at conferences from the professional organisations hosting
the conferences. She chaired the back pain expert group for the 2010
Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study. She
was appointed to the Australian Medical Services Advisory Committee
in May 2016. She has published multiple papers on low back pain, some
of which might be referenced in the series.
LMC is chief investigator or associate investigator on multiple previous and current research grants
from government research agencies FAPESP and CNPq from Brazil.
She has published multiple papers on low back pain some of which
may be referenced in the series.
PC has been chief investigator or
co-investigator on multiple previous research grants for musculoskeletal
pain research from UK government agencies (including National
Institute for Health Research and the Medical Research Council) and
UK charitable organisations (Arthritis Research UK and the Wellcome
Trust), but none from industry. His travel expenses have been covered
by the organising professional organisations (including rheumatology,
pain specialists, physical therapy, primary care) when he has been an
invited speaker at conferences. He has received honoraria for reviewing
grant proposals from government organisations in Canada, Norway and
PC’s department has received payment for two reports to the
UK Committee on Advertising Practice. He has published multiple
papers on low back pain, some of which might be referenced in the
BÖ is head of research at the division and is responsible for
previous and ongoing research funded by government research
agencies in Sweden. She has received travel expenses for speaking at
conferences from the professional organisations hosting the
conferences. She chaired the Scientific Council of Medicine and Health
from 2013 to 2016 and has been a member from 2010 to 2012.
MS receives most of his funding from the publishing company Wolters
Kluwer for writing and editing an international newsletter on spine and
back pain research (The BackLetter). He authors all the articles and
shares editorial control with the executive editor (a researcher, academic
spine surgeon, and Chairman, Department of Orthopaedics at
Georgetown University Medical Center). Neither has any conflicts of
interest with drug or device companies.
MS has co-authored several editorials for journals owned by publishers (The Spine Journal and
Spine—owned respectively by Elsevier and Wolters Kluwer). The
editorials concerned the inadequacy of the evidence base for regulated
surgical devices or drugs and biologics. He received nothing of value for
those editorials. The remainder of his funding comes from the
non-profit Sports Health and Safety Institute at the University of
Washington for research, writing, and editing in the concussion area.
He was previously a paid consultant for the non-profit Informed
Medical Decisions Foundation in Boston, involved in the preparation of
Decision Aids and Shared Decision Making materials. He occasionally
receives travel funding from professional societies to take part in
symposia sponsored by those societies.
MS has been an unpaid editorial board member and Consumer Representative at the Cochrane
Collaboration Back and Neck Group since 1999.
MvT is chief investigator, or co-investigator on multiple previous and current
research grants from government research agencies in the Netherlands
(ZONMW; the Dutch Health Insurance Council) and Australia
(NMHRC). His research has also received funding from professional
organisations (eg, the Royal Dutch Association for Physiotherapy,
the Netherlands National Chiropractic Association, and the European
Chiropractic Union). His travel expenses have been covered by the
organizing professional organizations when he has been an invited
speaker at conferences. He has received honoraria for reviewing grant
proposals from the Swedish Medical Research Council and VINNOVA
(Sweden’s innovation agency). He has not received any honoraria or
travel expenses from the industry.
MvT was chairman of the Netherlands National Multidisciplinary Guideline on Low Back Pain.
He has published multiple papers on low back pain, some of which
might be referenced in the series.
AW has been chief investigator or co-investigator on projects to identify burden of musculoskeletal
conditions and to develop strategies for their control. He has been an
expert adviser to WHO. He is chair of the Global Alliance for
Musculoskeletal Health. The European Community, professional
bodies, and research agencies have supported his work. Professional
bodies or organisers of scientific meetings have supported his travel
expenses. He has not received any funding from the private sector.
There was no funding for this paper. RB is supported by an Australian
National Health and Medical Research Council (NHMRC) Senior
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