Low back pain affects an estimated 540 million people worldwide, and a new study says too many patients receive the wrong care.
A new Series of papers in The Lancet highlights the extent to which the condition is mistreated, often against best practice treatment guidelines.
The researchers state that 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. They commented that 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 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,” said Series author Professor Rachelle Buchbinder, Monash University, Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”
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.
Low back pain results in 2.6 million emergency visits in the USA 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 USA. Additionally, only about half of people with chronic back pain in the USA have been prescribed exercise. In India, studies suggest that bed rest is frequently recommended, and 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,” adds Series author Professor Nadine Foster, Keele University, UK.
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,” says 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.”
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