Almost everyone will experience low back pain at some point. For some, it can become a chronic, debilitating condition, a lifelong burden with no easy fix. Most will get better, but an increasing number of people are considering major medical interventions to turn the tide.
The surgeons who are asked to help people deal with the problem (a problem for which there are sometimes no solutions) want sufferers to understand the limitations. They also suggest that low back pain is made worse by feeling as if you are carrying the weight of the world on your shoulders.
The Global Burden of Disease Study has declared lower back and neck pain to be Australia’s leading cause of ongoing disability and poor health. It ranked more highly than ischaemic heart disease (the leading cause of premature death) and depressive disorders, and the years lost because of this disability have increased significantly.
Anyone who has suffered low back pain will know it sometimes comes unexpectedly or grinds away over time, and the cause is sometimes no more obvious than the clinical diagnosis.
According to the WHO, there is a need to target preventable risk factors and research the risk factors that aren’t necessarily preventable.
“Low back pain is becoming more prevalent in our societies because of a number of factors that could be modified,” the WHO states. “Factors such as prolonged sitting position at the workplace, lack of exercise, obesity and high body weight account for factors that can be modified.
“Other risk factors such as anthropomorphic characteristics, gender, age and genetics are not modifiable. The physical disability arising from pain and loss of functional capacity reduces quality of life and increases the risk of further morbidity, although there is a wide range of analgesics available that relieve pain and improve quality of life for patients.”
Low back pain is a common complaint in general practitioner consultations and, with or without a proper diagnosis, the reason some people take heavy pain medication. But such pain also can lead to the abuse of painkillers, experimentation with other fixes and a belief that, with all the other advances in medicine and new technology, perhaps surgery will alleviate the pain and return the sufferer to full health.
According to Leigh Atkinson from the Wesley Pain and Spine Centre in Brisbane and Andrew Zacest from the Royal Adelaide Hospital, dealing with patient expectations is becoming increasingly difficult.
Writing in the Medical Journal of Australia this week, the associate professors say that while there is “an encyclopedic range of medical and alternative treatments for low back pain”, most have little benefit. That, in turn, leads people to surgery.
“Armed with mobile phones, consumed with social media, and with rapid access to online information, our patients present with high expectations of modern technology, including surgery,” they write. “With outstanding results from hip and knee arthroplasties (surgery to restore the function of a joint), they expect similar results from spinal surgery. Not uncommonly, the patient attends the surgical consultation with an expectation that the problems can be fixed.”
It seems spinal surgery is not so much seen as a worst-case scenario for some patients but a complete and lasting solution. Operations involving spinal fusion — where vertebrae are fused together to stop painful movement — reportedly increased by 175 per cent across 10 years in Australia, despite the obvious risks with such procedures.
There is also limited evidence of long-term benefits for patients who undergo spinal fusion. One estimate suggests the surgery cost $2.3 billion across 10 years despite more than 50 per cent of operations later being deemed unnecessary.
Not surprising, then, that amid the present push to ensure medical interventions are evidence-based and appropriate, the problem of dealing with low back pain is high on the agenda.
There is no doubt that low back pain is debilitating. It affects work and play and is nondiscriminating, with a lifetime prevalence of 80 per cent. As Atkinson and Zacest write, low back pain “affects adolescent sportsmen, pregnant women, hospital nurses and middle-aged labourers, and it peaks in the elderly”.
The George Institute for Global Health and the NPS Better Choices, Better Health campaign have given GPs advice on how to handle low back pain. They advise doctors to look for risk factors that suggest an underlying serious cause, one that justifies imaging, and otherwise seek to help the patient manage their pain and movement issues.
Acute low back pain usually gets better on its own without the need to see a doctor. Anti-inflammatory drugs can help in the short term and people should try to get moving again as soon as possible, stretching and strengthening as they return to normal.
If pain persists, obviously see a doctor. But, as the Choosing Wisely Australia campaign shows, some people go straight to the doctor, believing there must be a serious underlying cause and insisting on diagnostic imaging that can be a waste of time and money.
“Low back pain is the third most common health complaint seen by Australian general practitioners,” says John Slavotinek from the Royal Australian and New Zealand College of Radiologists. “Imaging for acute low back pain … is not recommended for patients with non-specific low back pain, which are the majority of these patients.”
For what it’s worth, the Australian Physiotherapy Association, in its Choosing Wisely recommendations, also urges against imaging for patients with non-specific low back pain.
Atkinson and Zacest warn that imaging on patients where there does not appear to be a serious spinal condition “tends to open Pandora’s box” and increase expectations that all these medical examinations will come to a conclusion. Too often, that conclusion is that spinal fusion may help. The surgery remains controversial and Atkinson and Zacest say further research is needed, perhaps through a national audit of spinal fusion outcomes, the same as has occurred with hip and knee arthroplasties.
If there is little evidence that spinal fusion helps, then what is sending patients down that path? Have we become so conscious of health issues that, in our ongoing struggle to be better people and do greater things, we are always dissatisfied and constantly searching for something more?
Atkinson and Zacest say there are certainly psychological and social factors that influence how people respond to lower back pain.
“The current high incidence of chronic low back pain in developed countries has little to do with biomedical explanations and is best understood in terms of a biopsychosocial framework, including work dissatisfaction, secondary gain and a cultural bias toward symptom relief,” they wrote.
“In Western medicine, current approaches to this problem, including the overuse of expensive diagnostic imaging, have failed and have in fact exacerbated the problem . The well-documented ageing of our population and our increasingly sedentary lives are enhancing the epidemic of chronic low back pain. ”
If surgeons such as Atkinson and Zacest caution against spinal fusions and the perception that surgery can fix all problems, then patients should definitely take a similar view. They see benefit in people with low back pain consulting an expert, getting a second opinion and attending an interdisciplinary pain clinic.
As with all healthcare, it is best to seek expert advice — and information to allow you to better understand that advice — before becoming fixated on a miracle cure. Putting such pressure on yourself, and the health system, may make your symptoms worse.
Source: The Australian