Friday, 19 April, 2024
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The high costs of lower back pain

Researchers into treatments for lower back pain, in an article in The Lancet, detail the overuse of inappropriate treatments such as common pain-killers including opioids‚ surgery and imaging‚ meaning patients are not receiving the right care. The Times reports that they also argue that significant health care resources are being wasted.

More than 30 leading experts from around the world contributed to the series of three papers‚ including Professor Quinette Louw of the division of physiotherapy at Stellenbosch University’s Faculty of Medicine and Health Sciences.

“The proportion of global disability due to back pain has doubled in the last 25 years and is a major reason of absenteeism in South Africa. Back pain causes more disability than lung‚ bowel and breast cancer combined‚ and this burden will increase in coming decades‚ particularly in low- and middle-income countries‚” said Louw.

“Research has repeatedly shown that most patients get the wrong care for low back pain. The implications are costly interventions which have low value. Decision makers from low- and middle-income countries must be made aware of these pitfalls in order avoid wasting scarce resources and harming patients‚” Louw added.

The report says worldwide‚ the review found low back pain is the leading cause of disability‚ affecting an estimated 540m people at any one time. Evidence suggests that low back pain should be managed in primary care‚ with the first line of treatment being education and advice to keep active and at work. However‚ in reality‚ a high proportion of patients worldwide are treated in emergency departments‚ encouraged to rest and stop work‚ are commonly referred for scans or surgery or prescribed pain killers including opioids‚ which are discouraged for treating low back pain‚ the articles state.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work‚” explained series author Professor Rachelle Buchbinder‚ from Monash University‚ Australia. “Often‚ however‚ it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

The report says the series reviews evidence from high- and low-income countries that suggests that many of the mistakes of high-income countries are already well established in low-income and middle-income countries. Rest is frequently recommended in low and middle-income countries‚ and resources to modify workplaces are scarce.

Examples cited include 2.6m emergency department visits for low back pain in the US each year‚ with high rates of opioid prescription. A 2009 study found that opioids were prescribed to around 60% of emergency department visits for low back pain in the US. Additionally only about half of people with chronic back pain in the US have been prescribed exercise.

In India‚ studies suggest that bed rest is frequently recommended while a study in South Africa found that 90% of patients received pain medicine as their only form of treatment. “In many countries‚ painkillers that have limited positive effect are routinely prescribed for low back pain‚ with very little emphasis on interventions that are evidence based such as exercises. As lower-income countries respond to this rapidly rising cause of disability‚ it is critical that they avoid the waste that these misguided practices entail‚” said series author Professor Nadine Foster‚ Keele University‚ UK.

The report says the Global Burden of Disease study (2017) found that low back pain is the leading cause of disability in almost all high-income countries as well as central Europe‚ eastern Europe‚ North Africa and the Middle East‚ and parts of Latin America. The global burden of disability due to low back pain has increased by more than 50% since 1990‚ and is due to increase even further in the coming decades as the population ages.

Low back pain mostly affects adults of working age. Rarely can a specific cause of low back pain be identified so most is termed non-specific and evidence suggests that psychological and economic factors are important in the persistence of low back pain.

Most episodes of low back pain are short-lasting with little or no consequence‚ but recurrent episodes are common – about one in three people will have a recurrence within one year of recovering from a previous episode – and, the report says, low back pain is increasingly understood as a long-lasting condition.

The authors say that health care systems should avoid harmful and useless treatments by only offering treatments in public reimbursement packages if evidence shows that they are safe‚ effective‚ and cost-effective. They also highlight the need to address widespread misconceptions in the population and among health professionals about the causes‚ prognosis and effectiveness of different treatments for low back pain.

“Millions of people across the world are getting the wrong care for low back pain. 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‚” said series author Professor Jan Hartvigsen‚ University of Southern Denmark.

“Funders should pay only for high-value care‚ stop funding ineffective or harmful tests and treatments‚ and importantly intensify research into prevention‚ better tests and better treatments.”

Executive Summary
Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, and it is increasing—disability due to back pain has risen by more than 50% since 1990. Low back pain is becoming more prevalent in low-income and middle-income countries (LMICs) much more rapidly than in high-income countries. The cause is not always clear, apart from in people with, for example, malignant disease, spinal malformations, or spinal injury. Treatment varies widely around the world, from bed rest, mainly in LMICs, to surgery and the use of dangerous drugs such as opioids, usually in high-income countries.
The Lancet publishes three papers on low back pain, by an international group of authors led by Prof Rachelle Buchbinder, Monash University, Melbourne, Australia, which address the issues around the disorder and call for worldwide recognition of the disability associated with the disorder and the removal of harmful practices. In the first paper, Jan Hartvigsen, Mark Hancock, and colleagues draw our attention to the complexity of the condition and the contributors to it, such as psychological, social, and biophysical factors, and especially to the problems faced by LMICs. In the second paper, Nadine Foster, Christopher Maher, and their colleagues outline recommendations for treatment and the scarcity of research into prevention of low back pain. The last paper is a call for action by Rachelle Buchbinder and her colleagues. They say that persistence of disability associated with low back pain needs to be recognised and that it cannot be separated from social and economic factors and personal and cultural beliefs about back pain.

[link url=""]The Times report[/link]
[link url=""]The Lancet Series[/link]

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