Transforming chronic low back pain management in Bangladesh: implications for rehabilitation in low- and middle-income countries

Abstract

Chronic low back pain (CLBP) is the leading cause of disability worldwide and represents a growing public health challenge in low- and middle-income countries. In Bangladesh, CLBP affects a substantial proportion of the adult population and contributes significantly to disability, reduced productivity, and healthcare utilization. Despite the high burden of disease, current management approaches frequently rely on pharmacological treatment and passive physiotherapy modalities that may not fully address the complex biopsychosocial nature of chronic pain. Sociocultural beliefs, limited patient awareness, and workforce constraints further influence care-seeking behavior and treatment practices. Contemporary clinical guidelines increasingly recommend biopsychosocial management strategies that emphasize active rehabilitation, patient education, and individualized care. The Specific Treatment of Problems of the Spine approach represents one such framework designed to deliver individualized physiotherapy for low back pain. This perspective highlights current challenges in CLBP management in Bangladesh and discusses how adopting individualized biopsychosocial physiotherapy models could improve outcomes. Strengthening rehabilitation capacity and integrating evidence-based physiotherapy into healthcare systems may provide a pragmatic pathway for improving CLBP care in Bangladesh and similar resource-limited settings.

Introduction

Low back pain (LBP) is the leading cause of disability worldwide and remains one of the most significant contributors to years lived with disability globally^[1^]. The burden of LBP has increased steadily over the past decades, particularly in low- and middle-income countries (LMICs) where healthcare systems often lack adequate rehabilitation infrastructure^[2^]. Recent global analyses indicate that millions of individuals experience persistent LBP, resulting in major economic and societal consequences^[3^].

Bangladesh, one of the most densely populated LMICs, faces a substantial burden of LBP. National survey data indicate that approximately one in five adults experience low back pain, with some occupational groups demonstrating even higher prevalence rates^[4^]. Chronic low back pain (CLBP) accounts for the majority of the disability burden and contributes to substantial productivity loss and reduced quality of life.

Despite the magnitude of this problem, effective management strategies for CLBP remain limited within the Bangladeshi healthcare system. Addressing this challenge requires a shift from traditional biomedical treatment models toward more comprehensive rehabilitation frameworks. Bangladesh represents a relevant example for many LMICs where shortages in rehabilitation workforce and reliance on passive treatment models continue to limit effective management of CLBP.

Current challenges in CLBP management in Bangladesh

In Bangladesh, the management of CLBP frequently involves pharmacological treatment provided by physicians, often supplemented by home remedies and, in some cases, surgical consultation. Physiotherapy is commonly recommended as part of the management pathway, although physiotherapists in Bangladesh are legislatively permitted to practice autonomously^[5,6^]. In practice, however, access to physiotherapy services often occurs within healthcare structures that remain largely physician-directed, which can influence referral patterns and the integration of rehabilitation approaches in routine care.

Evidence suggests that many physiotherapists continue to rely heavily on passive treatment modalities such as short-wave diathermy, traction, and ultrasound^[7^]. In contrast, evidence-supported interventions including exercise therapy and patient education are less consistently applied in clinical practice.

Workforce limitations further complicate this issue. Bangladesh currently has only a limited number of trained physiotherapists relative to its large population, which restricts access to evidence-based rehabilitation services. Consequently, many individuals with CLBP receive treatments that do not fully align with contemporary clinical guidelines^[2,8^].

Sociocultural influences on care-seeking behavior

Beyond structural limitations, sociocultural factors play a crucial role in shaping how individuals seek treatment for CLBP in Bangladesh. Qualitative research involving Bangladeshi adults with chronic LBP demonstrates that many patients have limited understanding of the underlying causes of their pain^[6^].

Patients often attribute their symptoms to factors such as excessive physical work, spinal injections during medical procedures, or vitamin deficiencies. Cultural beliefs and traditional healing practices also influence treatment decisions, with many individuals initially seeking help from family members, traditional healers, or informal networks before consulting healthcare professionals.

Physician authority strongly influences healthcare decisions in Bangladesh. As a result, physiotherapy is frequently perceived as a secondary treatment option and is typically pursued only after other interventions have failed^[6^]. These findings highlight the importance of culturally sensitive patient education and improved awareness of evidence-based rehabilitation approaches.

Moving toward a biopsychosocial model of care

Contemporary international clinical guidelines increasingly recommend biopsychosocial approaches to the management of CLBP^[8^]. This model recognizes that biological, psychological, and social factors all contribute to the development and persistence of chronic pain.

Biopsychosocial care prioritizes active treatment strategies including exercise therapy, patient education, and behavioral interventions that support self-management and functional recovery^[2,8^]. In contrast to passive modalities, these approaches aim to empower patients and address the broader determinants of pain-related disability.

Although multidisciplinary rehabilitation teams represent the ideal model for CLBP management, implementing such comprehensive programs can be challenging in LMIC settings due to financial and workforce constraints^[9^]. Nevertheless, strengthening physiotherapy-led rehabilitation services may offer a feasible pathway toward improving CLBP care.

Individualized physiotherapy and the STOPS approach

The Specific Treatment of Problems of the Spine (STOPS) approach represents a structured physiotherapy framework designed to deliver individualized biopsychosocial care for patients with LBP^[10–12^]. The STOPS model emphasizes detailed clinical assessment, classification of pain mechanisms, and tailored treatment strategies that address both physical and psychosocial contributors to pain.

Clinical trials conducted in Australia have demonstrated that individualized physiotherapy approaches based on the STOPS framework can improve patient outcomes and may also be cost-effective^[13^].

A prospective implementation trial is currently underway to evaluate the feasibility and effectiveness of the STOPS approach for managing CLBP in Bangladesh^[14^]. This study will compare individualized physiotherapy with usual care and assess clinical outcomes, implementation feasibility, and cost-effectiveness within the Bangladeshi healthcare context.

If successful, this approach could provide a scalable model for delivering evidence-based rehabilitation in Bangladesh and other LMICs facing similar healthcare challenges.

Future directions for CLBP care in Bangladesh

Improving CLBP management in Bangladesh will require coordinated reforms across multiple levels of the healthcare system. Key priorities include expanding the physiotherapy workforce, strengthening professional training in evidence-based rehabilitation, and integrating physiotherapy services more effectively into primary healthcare.

Public education initiatives may also help reshape patient expectations and encourage the adoption of active management strategies. By improving awareness of modern rehabilitation approaches, healthcare systems can support patients in transitioning away from passive treatment models toward more effective, evidence-based care.

Conclusion

Chronic low back pain represents a significant public health challenge in Bangladesh and contributes substantially to disability and lost productivity. Current management approaches often rely on passive interventions that may not adequately address the complex biopsychosocial nature of CLBP.

Transitioning toward individualized physiotherapy frameworks such as the STOPS approach offers a promising pathway for improving patient outcomes. Strengthening rehabilitation capacity and promoting evidence-based physiotherapy practices will be essential for modernizing CLBP care and reducing the long-term burden of low back pain in Bangladesh.

Ethical approval

Not applicable.

Consent

None.

Sources of funding

Not applicable.

Author contributions

M.A.: Conceptualization, methodology, investigation, writing – original draft. J.J.F.: Supervision, methodology, writing – review & editing. A.H.: Investigation, local supervision, writing – review & editing. A.J.H: Conceptualization, supervision, writing – review & editing.

Conflicts of interest disclosure

M.A. is a permanent employee of Uttara Adhunik Medical College Hospital. He is supported by a La Trobe University Full-Fee Research Scholarship (LTUFFRS) and a Low Back Research Team PhD Scholarship at La Trobe University, Australia. Associate Professor J.J.F. is a director of Advance HealthCare and the Ford Family Trust, which provided a philanthropic funding grant to the Low Back Research Team at La Trobe University, led by the chief investigator, Professor A.J.H., to support research on low back pain. Associate Professor J.J.F, as one of the investigators for this project, but did not participate in data collection or analysis. Professor A.H. provided in-country supervision to the PhD student in Bangladesh and was not involved in data collection.

Research registration unique identification number (UIN)

Not applicable.

Guarantor

Mohammad Ali.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the primary author used ChatGPT-4o version to assist with English grammar editing only. After using this tool, the authors reviewed and edited the final content and took full responsibility for the content of the published article.