Low back pain: a comprehensive review of The Lancet Low Back Pain Series

Lancet low back pain series is a series of three papers published in the Lancet Journal in 2018. The most important message highlighted by these papers, according to the Lancet, is quoted here:

A major challenge will be to stop the use of harmful practices while ensuring access to effective and affordable healthcare for people with low back pain. (THE LANCET)

Here we will discuss each paper in sequence as published in the Lancet journal, starting with the first paper (1) and then proceeding to the second (2) and third paper (3).

In this blog, we will discuss paper number 3: Low Back Pain: a call for action.

LOW BACK PAIN: A CALL FOR ACTION (3)

In this 3rd paper, the authors of the Lancet low back pain series talk about what we know and what we do in the clinic. They talk about some promising solutions and call to action in health policy within this area and a change in health policy that the authors think is desperately needed to reverse the burden of disability from low back pain.

The authors suggest the de-implementation of harmful practices, implementation of rational and evidence-based treatments, and making that available and affordable to patients globally.

GAPS BETWEEN EVIDENCE AND PRACTICE

• Guidelines consistently advise that low back pain should be managed in primary care, and yet an increasing number of patients presenting to emergency departments or medical specialists with low back pain because of the lack of access to good primary care.
• In primary care education, advice should be provided, but it is not the case in primary care settings.
• Guidelines recommend that patients should remain active and work, but we still see many clinicians and patients advocating rest and absence from work.
• According to guidelines, imaging should be done only in cases where we are suspicious of a specific condition requiring different management. But still, in high-income countries, even though the cause of low back pain is rarely identified, the imaging rate is high.
• Guidelines recommend that the first-line therapy should be non-pharmacological, but in practice, this approach is not followed.

Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

• Most guidelines are against electrical and physical modalities use (like short wave diathermy, traction) in acute low back pain, but these are still in use worldwide.
• Opioids are not recommended in case of low back pain, but we still see that opioids are overused in low back pain despite the guidelines recommendations.
• In non-specific low back pain, injections and surgeries have a limited role but are still widely performed in high-income countries.
• Exercises are recommended for chronic low back pain, yet clinicians’ preferences and healthcare constraints are against these recommendations.
• According to most guidelines, the biopsychosocial model should guide the management of low back pain, but the model is rarely followed in clinical settings, and clinicians focus mainly on the biological or structural component of low back pain.

Figure reproduced from Jan Hartvigsen's lecture on the Lancet Low Back Pain Series, Trustme-Ed

EXAMPLES OF POOR MANAGEMENT OF LOW BACK PAIN FROM DIFFERENT COUNTRIES AROUND THE WORLD

• In Australia, for example, only 21% of general practitioner consultations provided advice for emergency presentations of low back pain (14).
• In Qatar, bed rest is the most commonly recommended strategy for low back pain management (15).
• In Iran, less than half of the MRIs taken were indicated in case of low back pain.
• In South Africa, 90% of patients with low back pain received pain medication as their sole treatment.
• These are just documented examples of the gaps between the evidence and practice, and there may be plenty of undocumented cases.

BACK PAIN; DISTURBING TRENDS

In the US, from 1997 to 2010 increase in the use of opioids and muscle relaxants at the expense of milder analgesics that may be shouldn’t have been used at all, and we are seeing an increase in the use of medical specialist referrals and imaging.

There is a noted steep rise in opioid prescription, rate of opioid prescription, and per capita consumption of opioids in different countries around the world (16). Figure reproduced from Deyo RA, Von Korff M, Duhrkoop D, BMJ, 2015.

FACTORS RESPONSIBLE FOR THE EPIDEMIC OF POOR CARE FOR LOW BACK PAIN

• Healthcare is considered a business worldwide rather than a care.
• The widespread misconception among both consumers and clinicians.
• A deeply embedded public, patient, and professional culture that is resistant to de-medicalizing back pain.
• Vested interests and funding arrangements reinforce wrong care and discourage right care.
• Fragmented and outdated models of care at the policy level healthcare organization and community level patient-clinician interaction level.
• About half of all patients presenting to a medical doctor consider low back imaging necessary (17).
• Many general practitioners think that people with back pain should not go to work, should rest instead of being active, and that scans and X-rays are helpful when they have these patients in their consultation (18).
• These wrong beliefs about what to do with patients were more prevalent in the general physicians who said they have a special interest in back pain.

SOLUTIONS AND PROMISING DIRECTIONS TO BE USED AS EXAMPLES FOR CALL TO ACTION IN THIS SERIES OF PAPERS (19).

The potential causes of epidemic of poor management for low back pain

• The separate education of Healthcare practitioners like doctors, physiotherapists, chiropractors, and other clinicians.
• They are taught in different institutions and taught different approaches, vocabulary, and not to work together with other healthcare professionals.
• This silo-based education of healthcare practitioners can be a potential culprit for poor management of low back patients because after graduation when they move into the healthcare system, patients become confused when they see different practitioners.
• In the medical curriculum, there is limited content on low back pain, and in some regions, there is no education about the management of patients with back pain. When we look at studies, back pain is one of the most common conditions that present to primary care physicians. So, there is a mismatch between the education of healthcare practitioners and the number of patients they see.
• Continued focus on the biomedical and diagnostic model.
• Optimism-bias and therapeutic illusion.

SOME PROMISING EXAMPLES AND SOLUTIONS THAT CAN ACT AS A CATALYST FOR CHANGE

• Sweden Physiotherapists training courses led to greater behavior treatment orientations (20). In Sweden physiotherapists are being trained to have a much more behavior treatment orientation compare to biomedical treatment orientation when they treat back pain.
• In USA there are centers of excellence in pain education that promote and teach current thinking, knowledge, and evidence on management of low back pain.

Health campaigns for the public, clinicians, and patients
In Victoria, Australia, there was an intense campaign regarding low back pain for five years. If we compare the results from Victoria to New South Wales and look at beliefs and behaviors in patients and clinicians, we can see a shift and change in knowledge and rational behavior in patients and clinicians in Victoria. According to these changes in the rationalization of beliefs and behaviors, there appears to be a potential for public health campaigns using modern social media (21).Figure reproduced from Buchbinder R, Jolly D, Wyatt M, BMJ, 2001.

Sick leaves and return-to-work rate
A study compared the return-to-work rate of sick-listed patients in six countries. The study observed a large difference in the return-to-work rate of sick-listed patients among the countries and found that Holland has a large return-to-work rate of sick-listed individuals compared to other countries. The major difference was seen between Holland and Germany. This difference does not mean that people in Germany do not receive any treatment, but they receive roughly the same amount and type of treatment compared to Holland (22).Figure reproduced from Anema, et al, Occup. Rehab, 2009.

This study shows that the construction of our social and healthcare systems has a huge impact on the disability burden. Holland has implemented a more rational care pathway for back pain integrated work disability prevention with primary care for back pain patients. By implementing these measures, there has been a one-third reduction in sick leaves and substantial savings of almost 1 billion euros over a period of five years. It can be the reason Holland is doing so well (23).
Figure reproduced from Lambeek LC, et al, 2001.

Reduce unnecessary referrals for imaging studies
It has been shown that if you make it difficult to order an X-ray, the clinicians are less inclined to order one. In the USA, some emergency departments implemented a special requisite form to order an X-ray. It was a bit difficult to fill, and the result was that the number of referrals for x-ray reduced by 37% (24).

In the UK, an experiment was conducted that included education messages with MRI feedback to family physicians. They saw that if you repeatedly told the family physician that this referral was not according to guidelines and recommendations, he changed his behavior and became more rational when ordering an MRI. It resulted in a 23% reduction in lumber MRI requests (25).

Stratified care for patients with low back pain (26)
Stratified care is an appropriate type of care provided that matches the patient’s risk profile.

• Benefits of stratified care
  - Accurate (it discriminates patients well)
  - Provides predictions that inform treatment choice, clinical care, and use of resources.
  - Can be implemented into practice.
  - Clinically effective.
  - Cost-effective.
  - Affordable.

Figure reproduced from Hill JC, et al, the Lancet, 2011.

CONCLUSION

1. Low back pain is an enormous health problem that does not receive sufficient attention in societies, healthcare systems, and research.

2. Decision makers need to change incentives to sick leave, inactivity, and healthcare by stirring patients into evidence-based care.

3. The treatments that are proven to be ineffective or harmful should be discarded and not reimbursed.

4. There is a need for better coherence between healthcare systems, social systems, and the workplace.

5. We need a massive investment in research with a special focus on effectiveness and implementation.

6. Strong and coordinated action is needed to address the global epidemic of poor care for low back pain.

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