Continuing with the second of three papers recently published in The Lancet regarding Low Back Pain. What guidelines are already in place, what’s actually occurring in practice and suggested solutions going forward.
What’s striking to me is the
clear evidence of substantial gaps between evidence and practice, that are pervasive
A few years after delving into this, I am still scratching my head how far behind we are in our medical and clinical practice given the evidence. Yet, I’m hopeful that as more and more of this gets into the public domain, much-needed momentum will begin to close the GAP. Particularly with the crisis we find ourselves in, the growing epidemic of opioid use which is literally, killing people.
What are the treatment guideline GAPS, as outlined in the paper?
study results of clinical practice and highlights the disparity between ten guideline recommendations and the reality of current health care.
Guideline Message: Low back pain should be managed in primary care.
Practice: in high-income, low-income, and middle-income settings, people with low back pain present to emergency departments or to a medical specialist.
Guideline Message: Provide education and advice.
Practice: in high-income, low-income, and middle-income settings this aspect of care is rarely provided.
Guideline Message: Remain active and stay at work.
Practice: in high-income, low-income, and middle-income settings, many clinicians and patients advocate rest and absence from work.
Guideline message: imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain.
Practice: although such specific causes of low back pain are rare, in high-income, low-income, and middle-income settings, imaging rates are high.
Guideline message: first choice of therapy should be non-pharmacological.
Practice: surveys of care show that this approach is usually not followed.
Guideline message: most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction).
Practice: worldwide these ineffective treatments are still used by the professionals who administer physical therapies.
Guideline message: due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged.
Practice: these medicines have been overused in some, but not all, high-income countries; low-income and middle-income countries seem to have very low rates of use.
Guideline message: interventional procedures and surgery have a very limited role, if any, in the management of low back pain.
Practice: these approaches are widely used in high-income countries, little evidence on their use is available for low-income and middle-income settings.
Guideline message: exercise is recommended for chronic low back pain.
Practice: clinician treatment preferences and health-care constraints limit uptake.
Guideline message: a biopsychosocial framework should guide management of low back pain.
Practice: the psychosocial aspects of low back pain are poorly managed in high-income, low-income, and middle-income settings.
As you can see, what’s recommended is not what’s being offered to people for treatment.
Though first line care is meant to be non-pharmacological,
a study from the USA showed that only about half of people with chronic low back pain are prescribed exercise. In Australian primary care and in the emergency department setting in Canada, the most common treatment is prescribed medication.
Then, there are the rates of imaging, even though it has a limited role to play (see previous post).
39% in Norway, 54% in the USA, 56% in Italy as three examples, presenting patients to emergency rooms are given imaging.
Even worse, opioids. Though data for effects of opioids for acute low back pain are sparse,
one study showed that they were prescribed for around 60% of emergency department presentations for low back pain in the USA.
More than half the total number of people taking opioids long-term have low back pain though NO randomized controlled trial evidence is available about long-term effects. Well, we can see some of the short-term effects taking place across our countries at the moment.
In terms of surgery, which has “a limited role for low back pain”,
studies from the USA, Australia and the Netherlands show frequent use of spinal fusion.
So the waste to our healthcare system is apparent, but the bigger cost is what’s happening to the people who are provided these treatments that have shown to have little success. They seem stuck in what seems a never-ending loop of pain.
“Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments, routine use of imaging and investigations is not recommended.
Little prevention research exists, with the only known effective interventions for secondary prevention being exercise, combined with education, and exercise alone.”
Where do we go from here?
“Promising solutions include focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.”
Current guidelines need to be utilized which we clearly see, they are not. There needs to be better integrated education of health-care professionals including a change to the clinical-care model. Revamping the “current models of health-care reimbursement, which reward volume rather than quality”. Integration of health-care and occupation interventions so we can get people back to work and back to their lives. Changes to compensation and disability policies. Finally, public health interventions to change public’s beliefs and behaviors.
Which brings us to the last of the 3 papers, Low back pain: a call for action, up next on the blog.