Too Many Patients Receive the Wrong Care For No. 1 Disability in the World

Mar 21, 2018 11:00 AM

Author: Bill Keshlear

Low back pain is the No. 1. cause of disability worldwide, but overuse of inappropriate tests and treatments such as imaging, opioids and surgery means patients are not receiving the right care, and resources are wasted, according to a University of Utah Health researcher and coauthor in a three-article series in the medical journal The Lancet.

While great progress has been made in tackling many causes of death and disability around the world, the global burden of low back pain is continuing to worsen. In the U.S., that burden has increased by more than 50% since 1990, and is due to increase even further in the coming decades as the population ages.

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 central Europe, 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; 3 million in the U.S.; and 300,000 in Australia.

“The sobering statistics about the global impact of low back pain on people’s function, ability to earn a living and overall quality of life clearly indicate a failure of health systems throughout the world,” said Julie Fritz, PhD, associate dean for research at the College of Health.

The Lancet project highlights the extent to which the condition is mistreated, often against best practice treatment guidelines.

“Numerous practice guidelines for managing low back pain exist and consistently advocate for an emphasis on remaining active, providing positive expectations of recovery for patients, while avoiding excessive rest, reliance on pain medication and unnecessary use of imaging tests,” says Fritz. “Actual care provided for patients who seek care for low back pain, however, falls far short of these recommendations. Evidence-practice gaps are evident in health care systems across the world in high, middle and low-income countries.” 

Instead of offering solutions to stem this epidemic, health care systems frequently exacerbate the burden of low back pain. In the U.S., health care providers too often rely on pain medication, particularly opioids, that have marginal benefit with high risk for side effects. A 2009 study found that opioids were prescribed to around 60% of emergency department visits for low back pain.

What’s more, low value services, including spinal surgery, injections and imaging are overused, while high value services such as exercise, behavioral and psychological interventions are under-utilized.

“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 co-author Professor Rachelle Buchbinder, Monash University, Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.” The Low Back Pain Series reviews evidence from high- and low-income countries suggesting that many of the mistakes of high-income countries are also well established in low-income and middle-income countries.

Low back pain mostly affects adults of working age. Rarely can a specific cause of low back pain be identified, so most is termed non-specific. Evidence suggests that psychological and economic factors are important in the persistence of low back pain. 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 1 year of recovering from a previous episode) and low back pain is increasingly understood as a long-lasting condition.

The authors 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.

“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 co-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,” he says.

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