Disability from LBP increased by over 50% since 1990 – Where we are going wrong?

This is a hard statistic and one that we must step back and analyze.

 

Low back pain is the most frequent reason to seek a health care provider².  It is estimated that 60-80% of the general population will experience low back pain during their lifetime².  The majority of low back pain will fully resolve within six weeks.  Therefore, no matter what treatment is given from a simple hot pack to complicated mobilizations, the majority of patients will be better in 6 weeks.  As a medical provider, you have to ask yourself, is it your magic touch or just time that improved your patients?  To be better than time, the majority of your patients must be better in less than six weeks.

 

Research has found the following to be directly linked to poor outcomes:

 

1. Passive Treatments: Bed rest, manipulations, massage, pills, surgery³.

“You need ME to fix YOU.” – This attitude robs a patient of their self-control.  It removes them from the driver’s seat of their own care.  Actively engaging the patient is the number ONE factor associated with a positive outcome^2,3.

 

2. Nocebo Effect⁴: Words matter!

What we say and how we say it, can reassure or install fear. Often, we do not realize how patients hang on our every word as the authority.  Instead of words like ‘injury, avoid, pain’, focus on ‘recovery, return, function.’  How often have you heard something similar to: “My doctor told me 20 years ago to never lie on my stomach, so I can’t.”   Without realizing it, we may be installing fear and anxiety fear-avoidance cycle.  Instead, on the very first visit, reassure the patient that the majority of those with low back pain do well and make a full recovery.  nous sounding diagnosis such as:

1. Degenerative Disc Disease = normal wear in anyone over 35yo.
2. Herniated disc = a small cut that heals with the proper care.

 

3. Surgeries and Unnecessary Radiographic Exams ^2,3 The rate of lumbar fusion surgeries have dramatically risen by 137% from 1998 -2008 and the cost has grown(Emergent surgery is noted only for red flags, such as spinal cord compression, cauda equina, unstable fractures, etc.)  By the time you are 40, 60% will have an asymptomatic disc bulge, 33% will have an asymptomatic herniation, and when you hit 50 years 80% have disc bulge and arthritis without any symptoms. These diagnoses alone, therefore can NOT be a reason for surgery and these age-related findings spur fear in those suffering.   Research has also shown that 70% of those with definite surgical indications or severe initial symptoms – recover.  Disc reabsorption naturally occurs and many with nerve compression from herniation or stenosis improve within a month. Natural history studies have also demonstrated that the largest herniations have the most significant degree of resorption, whereas contained herniations demonstrate the least. Size is not a reliable staple for surgery ⁸.  Fusion of a joint is severe and should only be used in cases of trauma when the joint has no integrity.  Fusions should not be used for arthritis or a simple tear in a disc.

 

5. Disability Payments, Workers Comp, and Fee for Service:  We need to rethink our disability system.  It is great to assist those in need, but how often does it instead, hold others back? Back pain should never be permanent nor should disability benefits. Lack of proper diagnosis and education are the number one cause of persistent back pain.  Chronic pain has many layers.  To prevent chronicity, we must start with proper and early care: 1. Mechanical assessment, 2. Education to empower, 3. Advice to stay active.  Medical costs and length of disability have shown to coincide with state-level workers’ compensation policies regarding wage replacement and medical benefits.   Shorter retroactive periods and early referral of injured workers to experienced occupational health care providers, reduce medical costs and duration of work disability.  Unfortunately, our current system rewards all of us if the employee requires more care, including the physician, TPA, nurse case manager, physical therapist an aggressive return to work, but we can’t just blame the injured worker when the statistics show that HMO patients require less medical treatments.  Costs associated with musculoskeletal disorders (MSDs) make up 4.5% of the US economy. CMS estimates that up to 50% of healthcare spending provides no value.  Unnecessary and inappropriate musculoskeletal care in the USA consumes 2.5% of entire US economy or $360 billion/year!  Our current healthcare system of treating Low back pain is NOT working and MUST be disrupted.

 

 

 

Research backed treatments that have been shown to have a positive influence on back pain:

1. Education to empower, reducing fear and avoidance behavior ^2,3.   Assure that your language and actions do not contribute to fear and avoidance behavior.  On day one, provide education to remain active and communicate the positive natural history of back pain.  Include the mechanical cause of the symptoms and effect of different postures on pain to empower the patient to control their own symptoms.  Fear can be disabling.  Catastrophic thinking or focusing on the worse case scenarios requires work.  Establishing a positive return to work goal will also assist in a positive perceived recovery.
2. Mechanical Evaluation to assess for Directional Preference ². Directional preference has been associated with excellent outcomes and has also shown to reduce fear and anxiety. ACOEM reviewed all the current research and found directional preference to be the only treatment with a positive outcome.  Idiopathic back pain means that we have not figured out the cause, but the cause does exist. ^(3).   Finding the true diagnosis or cause of symptoms is the foundation for treatment.  Without a solid foundation, there is nothing to base treatment upon.  Other therapies that are currently widespread lack evidence for effectiveness.³
3. Maintain activity and keep working ^2,3  Keeping the individual suffering from low back pain moving has a better outcome than any manipulation, mobilization, release or surgery! There are times when activity does need to be modified, but modification should only be for a short period.  The goal must always be to return to full function/work duty as achievable.  Aerobic activity has also been associated with positive outcomes.

 

References:

1. Global Burden of Disease, Injury Incidence, Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study. Lancet. 2016; 388:1545-1602. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31678-6/abstract

 

2. Hegmann, k etal. Low Back Disorders Guidelines. American College of Occupational and Environmental Medicine. 2016  https://www.dir.ca.gov/dwc/MTUS/ACOEM-Guidelines/Low-Back-Disorders-Guideline.pdf

 

3. Buchbinder, R, van Tulder, M, Öberg, B et al. Low back pain: a call for action. Lancet. 2018;(published online March 21.) http://dx.doi.org/10.1016/S0140-6736(18)30488-4

 

4. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders. 2018;19:27. doi:10.1186/s12891-018-1943-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778801/

 

5. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BIUS. Trends in lumbar fusion surgery for degenerative conditions. Spine. 2005;30:1441-1445  https://www.ncbi.nlm.nih.gov/pubmed/21311399

 

6. Foster, NE, Anema, JR, Cherkin, D et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018

 

7. Werneke, MW et al. Directional preference and functional outcomes among subjects classified at high psychosocial risk using STarT. Physiother Res Int. 2018(3)14.  doi: 10.1002/pri.1711. https://www.ncbi.nlm.nih.gov/pubmed/29536595

 

8. Marsh L, et al. Radiculopathy and the Herniated Disc. Controversies Regarding Pathophysiology and Management. J Bone Joint Surgery Am. 2006(88)9:2070-80. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.837.6367&rep=rep1&type=pdf

 

9. Steffens, D, Maher, CG, Pereira, LS et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176:199-208.

 

10. Shriam M, et al. Length of Disability and Medical Costs in Low Back Pain: Do State Workers’ Compensation Policies Make a Difference? J Occ and Env Med:2015(12):1275-1283. doi: 10.1097/JOM.0000000000000593 https://journals.lww.com/joem/Fulltext/2015/12000/Length_of_Disability_and_Medical_Costs_in_Low_Back.4.aspx

 

11. Buchbinder R, etal. Low back pain: a call for action  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext