Gaps in knowledge highlighted for Back pain techniques

^{The papers should 'prompt some serious reflection among professionals' said the CSP}

The papers, written on behalf of the Lancet Low Back Pain Series Working Group, look at the impact of this leading cause of disability worldwide. This international group includes CSP member Nadine Foster from Keele University, one of the papers’ lead authors.

The Lancet reports that, globally, the number of years lived with disability caused by low back pain has increased by 54 per cent between 1990 and 2015, mainly because of population increase and ageing.

Professor Foster suggests that gaps between evidence and practice exist worldwide. She suggests there is limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery.

Doing more of the same will not reduce back-related disability or its long-term consequences, she argues.

She also looks at what evidence there is to show how effective various interventions are, globally, for preventing and treating low back pain and the recommendations from best practice guidelines.

‘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,’ said Professor Foster. ‘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.’

She concludes that there is little research into the effectiveness of prevention. The only interventions shown to be effective for secondary prevention are exercise combined with education, and exercise alone.

Drug therapies

She also examines the use of pharmacological interventions, although these are now only considered an option after other non-pharmalogical interventions have failed.

‘Paracetamol was once the recommended first-line medicine for low back pain; however, evidence of absence of effectiveness in acute low back pain and potential for harm has led to recommendations against its use,’ she states.

‘Health professionals are guided to consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account risks, including gastrointestinal, liver, and cardiorenal toxicity, and if using, to prescribe the lowest effective dose for the shortest possible time.

‘Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction potential, and poorer long-term outcomes than without use.’

The most disturbing risks related to use of opioids are addiction, overdose, and death. In the USA, prescription opioid-related deaths were around 15 000 in 2015, she states.

Professor Foster highlights a number of unnecessary interventions used globally, including:

• lumbar imaging, which means exposure to radiation
• liberal use of imaging, which triggers additional medical care including specialist referral, surgery, interventional procedures and potential absence from work

She adds that the growing use of complex fusion procedures in patients older than 60 years, who are undergoing decompressive surgery for spinal stenosis, is concerning.

‘These fusion operations are three times more expensive than decompression alone,’ she says

However, in the Netherlands, sick leave for low back pain fell by a third between 2002 and 2007. The total costs of back pain fell from €4·3 billion in 2002 to €3·5 billion in 2007.

New health insurance and sickness benefit laws in the last two decades may be behind this as a worker can – after a medical assessment – return to work on a part time basis while retaining some of their disability benefit.

Professor Foster suggests the financial incentive to resume work in line with the worker’s remaining work capacity has led to a large drop in sickness absence and disability pensions.

Similar solutions elsewhere ‘could potentially be replicable and cost-effective in other settings’ suggests Professor Foster.

CSP’s response

Responding to the papers in the Lancet, Steve Tolan, head of practice at the CSP, said:

‘That so many people start out with minor back pain and go on to suffer life-changing consequences is bad enough; that healthcare professionals contribute to that journey is unconscionable.

‘This landmark series of articles must prompt some serious reflection among professionals and decision-makers to ensure that when people seek help, what they receive is effective, proportionate and above all, empowering.

‘Through our own mythbusting initiative, we have sought to debunk misconceptions and deliver information that people can use to rationalise and manage the pain that so many of us will experience at some point in our lives.

‘It is absolutely essential that we cut through the noise with these messages and it is to be hoped that today’s publication leads to a tangible difference in the way back pain is both talked about and treated.’