ARTICLE
Low back pain is the single biggest cause of years lived with disability worldwide, and a major challenge to international health systems. Can modern health systems deliver the required care that current guidelines call for? The research presented here demonstrates that it may not be the “usual and customary” approach. In 2018, Lancet articles summarized the strong evidence that unnecessary care, including complex pain medications, spinal imaging tests, spinal injections, hospitalization and surgical procedures, is hazardous for most patients with low back pain. The Lancet working group called on the World Health Organization to increase attention on the burden of low back pain and “the need to avoid excessively medical solutions.” All six of the major international clinical guidelines released since 2016 prioritized non-pharmaceautical approaches for patients with low back pain. For patients at risk of developing chronic pain and disability, clinicians would, depending on which guidelines they followed, consider offering treatments such as spinal manipulation, massage, acupuncture, yoga, mindfulness, psychological therapies or multidisciplinary rehabilitation. Most health systems are not well-equipped to support this approach. Studies estimated that 28% of health care for low back pain in Australia and 32% of health care for low back pain in the United States was discordant with clinical guidelines. Some results of this inability to comply adequately with clinical guidelines include 3–4% of the adult United States population (9.6 million to 11.5 million people of 318.6 million) being prescribed long-term opioid drug therapy, in many cases because of chronic low back pain. Simple imaging tests were requested in one quarter of back pain consultations and the rates of complex imaging had increased over 21 years, and while there is no robust evidence of benefit for spinal fusion surgery compared with non-surgical care for people with low back pain associated with spinal degeneration, over the years 2004–2015, elective spinal fusion surgery in the United States increased by 62.3% with hospital costs for this procedure exceeding $10 billion dollars in 2015. While most people with low back pain will require little formal care, for those who do require extra help an immediate challenge is patients’ and clinicians’ lack of access to the recommended therapies. For example, a German survey found that general practitioners fundamentally agreed with the content of clinical guidelines for low back pain, but almost half had no access to the recommended multidisciplinary approach to pain management. A more recent qualitative study of general practitioners in the United Kingdom of Great Britain and Northern Ireland concluded the same. Bringing together necessary health services for people with complex chronic conditions is a growing challenge for modern health systems. People living in rural and remote areas are often unable to access multidisciplinary pain management because it is typically provided in tertiary health-care settings in cities. Patients may also have limited access to recommended SMT, physical and psychological therapies, and complementary therapies such as tai chi and yoga. Access is a problem, but it is also common that governmental and care management industries provide too little access to recommended treatment called for in the guidelines, or they impose unrealistic limits. For example, guidelines require longer, more complex consultations, yet general medical practitioners cite time pressure and lack of confidence in new approaches to care as barriers to adherence to guidelines. One survey of 6588 consultations for low back pain in Australia found that only around one fifth (21 of 100) of general practitioners took time to perform a complete history and physical examination. Not only are the misconceptions about management from regulatory authorities, but misconceptions about management of low back pain remain common among the populace. For example, around half of patients presenting with low back pain believed diagnostic imaging tests were necessary before treatment. Targeting misconceptions at the population level through mass-media campaigns is an effective, but costly, approach. The growth of social media should make similar campaigns easier and cheaper to implement. Targeting young people through health information messages on social media or other channels before unhelpful beliefs become entrenched is a worthwhile approach. Clinicians require more training and educational support from health systems if they are to use new approaches to back pain care. Educational materials and workshops can improve care quality. Key topics could include emphasizing the need for a history and physical examination in patients with low back pain and building skills in addressing patient concerns and requests for unnecessary care, such as imaging tests in the absence of clinical features of serious pathology. Decision-making shared with the patient can reduce unnecessary tests in other non-serious pain conditions. Partnering with clinicians independent of health system management rather than shutting them out of the system needs investigating. Delivery of guideline-concordant care for low back pain requires system-wide changes. Changes to governance arrangements will have to occur not just in health systems, but also in the complex framework in which health systems operate. Encouraging a shift away from unnecessary medical care requires support from governments, workplaces, legislative systems, consumers and professional bodies. Strong governance at each level of the health system will be key to redefining how society views and manages low back pain. Health systems should prioritize policies that: empower clinicians and consumers to make well-informed choices; encourage clinicians to deliver the right care to those who need it most; provide financial support to evidence-based non-pharmacological treatment; and regulate the influence of those with vested interests in the current situation. Source: https://www.who.int/bulletin/volumes/97/6/18-226050/en/