When we started talking to patients about back pain while building 76 Health, the same complaint kept surfacing.
"I've had three opinions. They all said something different."
We started looking at the published literature to see what the evidence actually says about how chronic back pain should be treated.
One reference kept coming up.
In 2018, The Lancet published a three-paper series on low back pain. It pulled together global epidemiology, treatment evidence, and a call for change. It's become one of the most cited references in modern musculoskeletal medicine — but it sits behind paywalls and uses clinical language most patients can't access.
Here's what we've been taking from it. Five observations from the series that we think matter most for anyone living with chronic back pain — or trying to help someone who is.
Low back pain is everywhere, and most has no clear cause
Low back pain is the leading cause of disability worldwide. That much is widely cited.
What's less widely cited is that for the vast majority of cases — somewhere around 85 to 90 percent — there is no clear, identifiable structural cause. No specific disc problem. No specific injury. No specific finding on imaging that explains the pain.
That doesn't mean the pain isn't real. It means the pain is what clinicians call "non-specific" — it has no single source you can point to.
This matters because the way the system tends to treat back pain assumes a structural cause that mostly isn't there. Imaging gets ordered to find something. Specialists get consulted to fix something. Procedures get scheduled to address something. And often, that something never gets identified because it was never the issue.
The Lancet's framing of this is matter-of-fact. Most low back pain is best understood as a complex condition that arises from a mix of physical, psychological, and social factors — not as a structural problem waiting to be solved.
Most current care isn't aligned with the evidence
This is the line in the series that's hardest to read if you've been a patient.
The Lancet authors looked at how back pain is actually treated around the world and compared it to what the evidence supports. The mismatch is significant.
Imaging is overused — frequently ordered when not indicated, and frequently leading to findings that don't change the treatment but do increase the patient's worry.
Opioids are overused for chronic back pain, despite limited evidence of benefit and substantial evidence of harm.
Surgery is overused for cases where conservative care would have worked, and underused for the small number of cases where it's clearly warranted.
Conservative care — movement-based therapy, education, psychological support — is consistently underused, despite the evidence supporting it.
The pattern isn't a few bad actors. It's the system's default.
Movement and education are first-line treatment
Across the series, the strongest evidence for non-specific low back pain points the same direction. Stay active. Don't bed rest. Move. Learn what the pain actually is and isn't.
This sounds underwhelming. The evidence base is not.
Multiple high-quality reviews show that staying active and engaging in graded, supervised movement produces better outcomes than rest, than passive treatments, and than waiting for imaging-driven interventions. Education about what back pain actually is — and isn't — reduces fear and improves how patients engage with their recovery.
Physical therapy and similar movement-based approaches sit at the center of this. Not as the only answer. As the first answer for most cases.
The mind and the social context aren't optional
Chronic back pain almost always has psychological and social dimensions. The Lancet series is explicit about this.
Patients with chronic back pain often experience anxiety or depression. Fear of movement and fear of re-injury can significantly worsen outcomes. Lack of social support, job dissatisfaction, and economic stress all affect how pain is experienced and how recovery progresses.
Ignoring these dimensions, or treating them as separate from "the real medical issue," makes recovery harder for most patients.
The implication isn't that back pain is in your head. The implication is that pain lives in a whole person, in a whole context, and that effective care has to address all of it.
The call to action
The third paper in the series is titled "A call for action."
The authors argue that the gap between what the evidence supports and what's routinely delivered for low back pain is so large that incremental change won't close it. They call for a coordinated, multidisciplinary response — one that aligns clinical care, payment, education, and research around the evidence.
Their framing is not that providers are doing the wrong thing in any individual encounter. It's that the system has evolved in a direction the evidence doesn't support, and that closing the gap requires structural change in how care is organized.
What we've been thinking about
Reading this series has shaped a lot of how we've come to think about coordinated care.
The first finding — that most back pain doesn't have a clear structural cause — pushes against the temptation to lead with imaging or specialist referral. The second — that most care is misaligned with evidence — explains why patients keep getting different answers from different providers. The third and fourth — movement-based therapy and psychosocial context as central — explain why a therapy-first, coordinated approach has the evidence behind it.
The fifth — the call for action — is what we've taken most seriously.
We're not going to fix the system at scale. What we can do is build a coordinated layer for the conditions where the evidence and the routine practice are most out of step. Chronic back pain is one of those.
We're early. We're learning. But the case for trying is one of the strongest in modern musculoskeletal medicine.
Sources: Hartvigsen et al., Foster et al., Buchbinder et al., "The Lancet Low Back Pain Series" (The Lancet, 2018).
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