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Low back pain often wrongly treated worldwide

Subject to inappropriate and costly tests and treatments; best practice guidance ignored

Caroline White

Friday, 23 March 2018

Despite being the leading cause of disability worldwide, affecting an estimated 540 million people at any one time, low back pain is frequently mistreated with costly and inappropriate tests and drugs, which run counter to best practice treatment guidelines, conclude a series of studies published in The Lancet.

The evidence suggests that low back pain should be managed in primary care, with the first line of treatment being patient education and advice to keep active and at work.

Yet a high proportion of patients worldwide are treated in emergency care, encouraged to rest and stop work, commonly referred for scans or surgery, or prescribed pain killers, including opioids.

“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,” explains series author Professor Rachelle Buchbinder, of Monash University, Australia.

“Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.” 

The series reviews evidence from high to low-income countries: rest is frequently recommended in low and middle income countries, and resources to modify workplaces are scarce.

Low back pain results in 2.6 million emergency visits in the USA each year, with high rates of opioid prescription. And only about half of people with chronic back pain in the USA are prescribed exercise.

In India, studies suggest that bed rest is frequently recommended, and a study in South Africa found that 90% of patients received painkillers 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,” adds series author Professor Nadine Foster, Keele University, UK.

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 in central and eastern Europe, North Africa and the Middle East, and parts of Latin America.

Every year, a total of 1 million years of productive life is lost in the UK because of disability from low back pain.

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.

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 low back pain is increasingly thought of as a long-lasting condition.

The authors say that health care systems should avoid harmful and useless treatments by only offering treatments if the evidence shows that they are safe, effective, and value for money.

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,” says series author Professor Jan Hartvigsen, University of Southern Denmark.

“Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and healthcare leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo,” he adds.

But Professor Helen Stokes-Lampard, chair of the Royal College of GPs, cautioned against adopting ‘a one size fits all approach’.

She said: "Lower back pain causes misery for a huge and growing number of patients right across the UK – it is something that GPs see in our consultation rooms on a daily basis, and what is clear is that one size does not fit all in terms of managing the pain.

"We know that being active and working is good for our patients' health, but for some patients, particularly in more serious cases, there is a limit to how realistic a significant amount of exercise is.

"For these patients whilst not a cure, drug therapy can provide a great deal of relief and should not be dismissed entirely - the most effective approach, as with any medication, is that it should be prescribed at the lowest possible dose for the shortest possible time. It is also the case that access to psychological treatments, such as talking therapies, which we know can be beneficial for patients suffering from lower back pain, is patchy across the country.

NICE guidelines in England currently advocate an approach that combines physical, psychological and pharmacological treatments.

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