According to the Global Burden of Disease Study 2010*, back pain is the leading cause of disability worldwide. In Western Europe, 15% of people suffer from back pain, while in the USA it’s thought that as much as 80% of the population experiences at least one episode of back pain within their lifetime*. With figures as striking as this, the news that the effective treatment of back pain has remained elusive on a global scale* has made it clear that we need to rethink how we deal with back pain.
Despite being extremely common, back pain is far from trivial. The experience is often agonising, making once active and confident people feel entirely incapacitated, and desperate for a quick and comprehensive solution. There is also a wider economic impact, with musculoskeletal issues (which include back pain, as well as neck and upper limb problems) creating 30.8 million days of sickness absence each year*. The cost to the NHS is estimated at £1 billion each year*.
However, experts believe that our approach to treating back pain is failing across the globe. So what exactly do they think the global medical profession is doing wrong?
The report which has highlighted these issues comprises of three papers published in The Lancet on March 21st 2018. The papers were completed by an international group of authors, led by Prof Rachelle Buchbinder of Monash University, Melbourne, Australia. The first paper concerns the complexity of lower back pain, and the psychological, social and biophysical factors which contribute to people’s experience of the condition.
The second addresses treatment, with experts outlining their recommendations and highlighting the lack of research into preventative measures. The third calls for more recognition concerning the precedence of disability associated with low back pain, and how connected social and economic factors (as well as personal and cultural beliefs) are to this issue.
How Back Pain Being is Mistreated
The report concludes that there major problems in how back pain is treated, including:
The use of painkillers
An example of how mistreatment of back pain can have extremely damaging consequences can be seen in the opioid crisis which is currently affecting the USA. In 2016, cases of Fentanyl (a strong opioid which is prescribed to help people manage pain) deaths had risen 540% in three years*, killing around 5,000 more people than heroin.
While effective in eliminating pain (they were traditionally prescribed to help people at the end of life, or who were dealing with very serious illnesses), painkillers such as OxyContin and Fentanyl do not address the root cause of back pain, and are highly addictive.
Despite this, between 1996 and 2002 prescriptions issued for OxyContin in the US increased tenfold, from 670,000 a year to more than six million. This is thought to have been due to an aggressive marketing campaign from manufacturers, who doubled their sales force, and distributed coupons so doctors could let patients try a 30-day free supply of these drugs.
While back pain isn’t the only complaint that can lead patients to opioids, the report expressed concern that prescriptions for back pain have been fuelling this crisis, stating that: “The epidemic of addiction and rising mortality resulting from increased opioid prescribing in the USA over the past 20 years is a dramatic example of the disastrous effects of damaging medical intervention.”
The rate at which the NHS prescribe opioid painkillers was also highlighted, with Prof Nadine Foster explaining that “recent trials have shown they are not more effective than other much safer drugs, yet many patients are still being put on drugs that have opioids in them.” People should be given “the safest possible drugs for the shortest possible time at the lowest possible dose”.
One of the big challenges in treating back pain is that, very often, it is difficult to find the cause. Prof Martin Underwood points out that “in the vast majority of cases we don’t know what the cause is”, and describes the counterproductive nature of using MRI scanners to try to identify it. While there is always some sort of trigger for back pain – whether it’s an injury or lifestyle factors such as obesity – MRI scans pick up physical problems that aren’t actually the source of the pain, and can result in surgical interventions which do not help.
The evidence shows that fusing the discs in the spine, inserting artificial discs or giving spinal injections does not usually address the problem. However, in some countries these interventions are a lucrative option, while in others there can be pressure from patients keen for a solution. In the NHS, fewer patients are offered fusion surgery, but many will be offered “injections that are of questionable value”, which represent a large expense at debatable efficacy.
The report also describes the lack of benefit in recommending bed rest and time off work to patients. Doctors across the globe may be reluctant to suggest anything which could exacerbate the issue, viewing bed rest as a “safe” option, but research demonstrates that extended periods of bed rest actually make back pain worse.
Clinical practise guidelines in the USA strongly recommend that patients remain active, while the NICE guidelines in the UK inform doctors to encourage patients to continue with normal activities, and if appropriate consider a group exercise program. However, bed rest is still common advice in many countries, and culturally speaking it’s something commonly believed to be the best solution.
The report’s experts have called for what they term a “positive health” approach. They want to change the perception of back pain, and help patients to stop expecting a definitive diagnosis or cure. Instead, they should be given the tools to “adapt and to self-manage, in the face of social, physical, and emotional challenges”.
Yoga therapy for back pain and sciatica is one such tool. It is now recommended in the NICE guidelines for doctors presented with patients suffering from the issue, and it empowers those who take part in the programs to look after their own health.
For most, painkillers are only a short-term option, and there simply isn’t a magic bullet to solve their back pain options in the form of surgery. The physical therapy offered by yoga improves the symptoms and stops them occurring again – the solution that many are looking for.