The dis-connect with low back pain

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How the evidence doesn’t support common practice and 10 pieces of advice to help you better navigate the complex world of low back pain. By Joshua Hallett.

It’s true. There currently exists a substantial disconnect between the evidence and the management most Australians will receive when they are struck down by disabling low back pain.

Last year the Lancet Journal (the world’s leading independent general medical journal) released a series of papers as a part of the Low Back Pain working group with recommendations for improved clinical practice guidelines for the assessment and management of low back pain with no known cause.

They found that despite increases in health care spending and advances in medicine,

“…low back pain is a major problem throughout the world and it is getting worse…years lived with disability caused by low back pain have increased by more than 50% since 1990 1

These changes are associated with an ageing and increasing population as well as lifestyle changes and shifts towards more sedentary work.

As you will see, as health professionals we have been letting you down. So let us set some things straight when it comes to back pain.

What do you need to know?
What can we do to get you better faster, while saving you time & money?
And what should you be looking out for?

1. You don’t need to go to hospital or the specialist.
Your chiropractor, general practitioner, osteopath and physiotherapist are all equipped and sufficiently trained to manage your low back pain (especially if they keep up to date with current research).

“Of 944 presentations for low back pain in an Italian emergency department in a year, 99.4% of patients were without conditions that were life-threatening or associated with high morbidity requiring prompt assessment and hospital admission 2,3

2. You should be provided with education and advice.
Low back pain can be severe and disabling, but it is important that you know that you do not have a serious disease and that symptoms will improve over time. This includes low back pain with severe leg pain (i.e. “sciatica” or the medical term for pain from the lower spinal nerve roots “radicular pain”). You should be encouraged to avoid bed rest, stay active and continue with usual activities including work.

“Advice was provided at only 21% of consultations with a general practitioner in Australia 2,4

3. Avoid bed rest, stay active and remain at work.
It appears us health professionals seem to be having a problem with conveying this message accurately, so there appears to be a lot of misinformation on this one. Yes, it can be wise to make modifications to your activities which will help. But often these modifications are all based around improving your ability to remain active and/or stay at work.

“Three surveys of Australian general practitioners in the period of 1997-2004 revealed that 24.5% of them who had a special interest in low back pain, endorsed the incorrect view that “Patients should not return to work until they are almost pain free” compared with 15.8% of those who did not have a special interest 2,5

4. You probably don’t need imaging.
Imaging should only occur if the clinician suspects a specific condition. I often tell my patients that making a diagnosis from imaging (X-ray, MRI etc) is the equivalent of taking a photo of a telephone and guessing if it is ringing! You need a lot more information than just a photo… so save your money, your time and avoid that extra radiation.

“A survey of all Australian chiropractors (n = 4859, 10% response rate) showed that 54% agreed that lumbar radiography is indicated for acute low back pain 2,6

“60% of people over the age of 50 who have never experienced back pain will have a disc bulge, 80% will have disc degeneration 17

5. You don’t need pain medication.
Pain is a protection mechanism. Why would we want to be less protected when we are injured? Yes, we can on occasion use medication, but it should not be the first choice of therapy and it definitely should not be the only form of therapy provided.

“A survey of Australian general practice care from 2000 to 2010 (21,350 patient encounters) showed that 64.5% of patients were prescribed a medicine at the first visit for a new episode of low back pain 2, 7.”

“A potential reason is the way in which health-care systems preferentially fund surgery and medicines over physical and psychological therapies 2

6. Most guidelines advise against electrical or passive physical modalities.
Endorsed forms of complementary medicine should be used in combination with the above guidelines. They include massage, acupuncture, spinal manipulation, Tai Chi and yoga 2.

“Ultrasound, transcutaneous electrical nerve stimulation (TENS), traction, interferential therapy, shortwave diathermy, and back supports are generally ineffective and not recommended 2, 8-10

7. Due to unclear evidence of effectiveness and concerns of harm, the use of opioid analgesic medicines is now discouraged.
Thankfully, access to opioids has been greatly reduced since 1 February 2018 and is now available only on prescription.

 “In 2016, the number of opioids deaths (1,119) was the highest number since the peak in 1999 (1,245 deaths)… Pharmaceutical opioids are responsible for more opioid deaths and poisoning hospitalisations than heroin 11”.

8. Interventional procedures and surgery have a very limited role.
A lot of patients are often worried that they may need surgery. This is very rarely the case. It is also important to know, that not every procedure comes with the same benefits and risks…

“The growing use of complex fusion procedures in patients older than 60 years undergoing decompressive surgery for spinal stenosis is concerning, since fusion operations are three times more expensive than decompression alone, and have double the rates of wound complications, cardiopulmonary complications (such as stroke), and 30-day mortality 2,12. Importantly, trials have clarified that adding spinal fusion to decompressive surgery for symptomatic spinal stenosis does not improve symptoms 2,13

9. You should exercise if you have chronic low back pain.
Theme alert! Sedentary lifestyles are associated with increased disability caused by low back pain. If you have low back pain, stay active, remain at work. If you are suffering with chronic low back pain a graded activity or exercise program that targets improvements in function and aims to prevent worsening disability should be undertaken. Getting a referral from your general practitioner to your local chiropractor, osteopath or physiotherapist can be a good start. If you have chronic low back pain and anxiety or depression, then seeing a psychologist or psychiatrist is also recommended.

“Medicare, has a limit of five allied health consultations, which is too few to deliver a typical exercise programme for chronic low back pain 2, 14, 15

“Only 12% of people with chronic low back pain with depression in the USA had seen a psychiatrist or psychologist in the previous year 16

10. A biopsychosocial framework should guide management of low back pain.
Pain is a protective mechanism. As a result it needs to provoke strong emotions to alter our behaviour. All pain is altered by our mood and social settings. As a result we must consider the whole picture when treating pain.

A great resource to learn more about pain and the biopsychosocial framework is the Explain Pain Handbook: http://www.noigroup.com/en/Product/EPBEII

So that’s it! 10 pieces of advice to help you navigate the complex world of lower back pain. I hope this helps you find the right approach, and in many cases, the right team of practitioners for you. I’d also recommend you be wary of any practitioners who want to lock you in to extensive treatment programs, pressure you into scans or considering surgery, or only offer you limited forms of treatment. The best practitioners take their time, help you make informed decisions, work with other health professions to provide you with the best care and motivate you to stick to your lifestyle goals.

I wish you all the best.

Dr. Joshua Hallett
Chiropractor & Managing Director 

Josh can be contacted at josh@connecthealthcare.com.au

References:
1) Low back pain: a major global challenge
S Clark, R Horton – The Lancet, 2018 – thelancet.com
https://scholar.google.com.au/scholar?hl=en&as_sdt=0%2C5&q=Low+back+pain%3A+a+major+global+challenge.&btnG=
2) Prevention and treatment of low back pain: evidence, challenges, and promising directions
Nadine E Foster, Johannes R Anema, Dan Cherkin, Roger Chou, Steven P Cohen, Douglas P Gross, Paulo H Ferreira, Julie M Fritz, Bart W Koes, Wilco Peul, Judith A Turner, Chris G Maher, on behalf of the Lancet Low Back Pain Series Working Group*
3) Profiling the patients visiting the emergency room for musculoskeletal complaints: characteristics and outcomes. Bellan M, Molinari R, Castello L, et al. Clin Rheumatol 2016; 35: 2835−39.
4) Low back pain and best practice care. A survey of general practice physicians. Williams CM, Maher CG, Hancock MJ, et al..
Arch Intern Med 2010; 70: 271−77.
5) Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Buchbinder R, Staples M, Jolley D.. Spine 2009; 34: 1218−26.
6) Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors. Jenkins HJ. Chiropr Man Therap 2016; 24: 39.
7) Ten-year survey reveals differences in GP management of neck and back pain. Michale ZA, Harrison C, Britt H, Lin CW, Maher CG. Eur Spine J 2012; 21: 1283−89.
8) National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. Eur Spine J 2018; 27: 60–75.
9) Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Ann Intern Med 2017; 166: 514−30.
10) UK National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. November 2016. https://www.nice.org.uk/guidance/ng59 (accessed Nov 7, 2017).
11) Australian Institute of Health and Welfare: Opioid harm in Australia: and comparisons between Australia and Canada.
Publication : https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/summary
Release Date: 09 Nov 2018
12) Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC,
Jarvik JG. JAMA 2010; 303: 1259−65.
13) A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. Forsth P, Olafsson G, Carlsson T, et al. N Engl J Med 2016; 374: 1413−23.
14) Motor control exercise for chronic non-speci c low
back pain. Saragiotto BT, Maher CG, Yamato TP, Costa LOP, Ostelo RWJG,
Macedo LG. Cochrane Database Syst Rev 2016; 1: CD012004. 88
15) Australian Government Department of Health. Chronic disease management – provider information: fact sheet. 2016. http://www.health.gov.au/internet/main/publishing.nsf/Content/ mbsprimarycare-factsheet-chronicdisease.htm (accessed 89 Mar 27, 2018).
16) A long way to go: Practice patterns and evidence in chronic low back pain care. Carey TS, Freburger JK, Holmes GM, et al. Spine 2009; 34: 718−24.
17) Systematic literature review of imaging features of spinal degeneration in the asymptomatic populations. W. Brinjikji, P.H. Luetmer, B. Comstock, B.W. Bresnahan, L.E. Chen, R.A. Deyo, S. Halabi, J.A. Turner, A.L. Avins, K. James, J.T. Wald, D.F. Kallmes and J.G. Jarvik. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.