Public health

Low back pain challenge: call to ban ineffective and harmful interventions

Leaders in the field of low back pain have called for global action to address the leading cause of disability across low, middle and high-income countries.

In a Lancet Viewpoint article, they called for low back pain to be recognised as a public health problem and for national and international funding agencies to make low back pain research a global health priority.

Against a background of iatrogenic harm including opioid addiction and deaths, they said the challenge was to prevent ‘harmful or wasteful’ practices for low back pain and ensure ‘equitable access to effective and affordable health care’ .

Melbourne rheumatologist and Chair of the Lancet Low Back Pain Series Working Group Steering Committee Professor Rachelle Buchbinder told the limbic ineffective and potentially harmful tests and treatments should not receive reimbursement.

“This is one of the most difficult issues for the MBS Review – identifying the group that do not benefit and may be harmed while not restricting access for those who may benefit.”

“Importantly we would also like to see more consideration of reimbursing high value care – so for example this might be reimbursing visits to a physiotherapist or exercise physiologist for exercise therapy for someone with back pain; or considering how to make psychological treatments more accessible and available for people at high risk of chronicity for back pain.”

The call to action included tackling vested interests, changing health care culture and systems, and changing clinician behaviour by addressing evidence-practice gaps.

Federal support

In Australia, the Federal Health Minister Greg Hunt has today (Thursday 2 March) launched the NHMRC Centre for Research Excellence for the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network.

The new CRE will assist by extending an already large multidisciplinary collaboration of leading and emerging researchers/clinicians across Australia and New Zealand.

Professor Buchbinder said CRE funding was primarily to support capacity building, training and mentorship to ensure the next generation of leaders could continue important work on back pain and other musculoskeletal conditions.

“They are huge asks but the ANZMUSC CRE is committed to ensuring that ANZMUSC trials only answer the most important questions from the perspective of patients and clinicians. And we plan to advance the science of implementation by trying to determine the best strategies for changing practice through a series of implementation trials.”

“In the back pain field for example, we are already doing an implementation trial to see whether a model of care for management of patients with low back pain in the emergency department is better than ‘usual care’.”

She said they would also be working with other groups and organisations such as Cochrane Musculoskeletal, Therapeutic Guidelines Ltd and the Australian Commission on Quality and Safety in Health Care to hasten the process between reviews and recommendations through living reviews and living guidelines; and looking at strategies to increase uptake of Clinical Care standards into practice.

Guidelines ignored

A related article in the Lancet Series identified a number of evidence-practice gaps related to low back pain, including:

  • Low back pain was a common presentation to emergency departments but should instead be managed in primary care
  • Education and advice about low back pain was important but rarely provided
  • Many clinicians were still advising bed rest instead of advocating for physical activity and return to work
  • Imaging rates were high despite rarely identifying specific causes of low back pain
  • The majority of patients are prescribed medications at first visits for low back pain when non-pharmacological alternatives should be the first choice
  • Electrical therapies are widely used but ineffective
  • Opioids are widely used despite dubious efficacy and known harms
  • Interventional procedures and surgery are widely used despite their limited role
  • Health care restraints limit prescription and uptake of exercise
  • Psychological aspects of low back pain are poorly managed.

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