The World Health Organization guideline for non-surgical management of chronic primary low back pain in adults: implications for equitable care and strengthening health systems globally

Abstract

The World Health Organization (WHO) released its first guideline on non-surgical management of chronic primary low back pain (LBP) in adults in 2023. The Guideline signals a timely and important global response to the current and projected burden attributable to LBP, particularly amongst populations made vulnerable, e.g. older people and people in low- and middle-income countries. The Guideline offers recommendations on which interventions for chronic primary LBP should be offered in most contexts, and those interventions that should not be offered as part of routine care. As a WHO technical product, the Guideline can function as a catalyst to commence reorientation of health systems and service delivery towards holistic, integrated, person-centred and high-value LBP care. However, to achieve this vision and Universal Health Coverage that is inclusive of LBP care, transformations are required at point of care (micro-level), within service models and organisations (meso-level) and across health system Building Blocks (macro-level). In this paper, we consider implications of the Guideline for health services and health systems globally. We highlight opportunities and priorities to build capacity across the Building Blocks of health systems and how current global health agendas, such as the WHO 14th General Program of Work, UN Decade of Healthy Ageing 2021-2030, and Rehabilitation 2030 can support implementation of the Guideline's recommendations. Global collaborative and multi-sectoral efforts, supported by countries, health workers, professional/academic societies, health financing agencies, civil society organisations, private sectors, and people with lived experience will be needed to sustainably implement the Guideline's recommendations into health systems globally.

Keywords: Chronic pain; Health policy; Health systems; Musculoskeletal; Universal Health Coverage.

Fig. 1

Summary of recommendations of interventions that may be offered as part of care in most contexts, and interventions that should not be used as part of routine care in adults experiencing chronic primary LBP, with or without spine-related leg pain, in community and primary care settings. All recommendations are relevant to older people, other than non-steroidal anti-inflammatory drugs (NSAIDs)—the recommendation in favour of using NSAIDs does not extend to older people. Interventions are organised by class and superscripts indicate the judgements of the certainty of the evidence made by the Guideline Development Group. No recommendations were made for 12 interventions, including: respondent therapy, cognitive therapy, mindfulness-based stress reduction therapy, paracetamol (acetaminophen), benzodiazepines, cannabis-related pharmaceutical preparations for therapeutic use, topical Brazilian arnica, ginger, topical white lily, topical combination herbal compress, topical combination transdermal diffusional patch, and non-pharmacological weight loss. Figure reproduced from WHO (https://www.who.int/publications/i/item/9789240081789) under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO).^a: moderate certainty evidence. ^b: low certainty evidence. ^c: very low certainty evidence. ^d: good practice statement

Fig. 2

Guiding principles for the management of chronic primary LBP in adults, reproduced from WHO (https://www.who.int/publications/i/item/9789240081789) under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO)