Tag: problem

Low Back Pain: GAPS between Guidelines and Practice

by Jody, posted in news

bettingrealitycheck

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?

Below are

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.

And,

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.

Key messages:

“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.

Low Back Pain – Extremely common, complex in nature and most often, not treated effectively

by Jody, posted in news

ape

Last week I wrote briefly about a recently published paper in the Lancet, picked up by the news in the UK, here, here, here, and here. Today, I’ve seen an article in the USA. So, far, one report that I can find, in Canadian news.  One headline from Monash University in Australia goes so far to say:

Global burden of low back pain – a consequence of medical negligence and misinformation

As mentioned, I said I would break down why I believe this is so important. The first paper (three in the series) is “What low back pain is and why we need to pay attention”.

Why should all of this matter to you? Why do you need to pay attention?

The median 1-year period prevalence globally in the adult population is around 37%, so chances are you or someone you know is affected.

And, what’s even more important, is

the way we have been treating people isn’t working.

“Low back pain (LBP) is now the number one cause of disability globally.”

There are a LOT of people who experience chronic or persistent low back pain.  On a purely personal note, I would say it is the most prevalent ‘problem’ people tell me about when they turn up at my yoga classes.

“Rarely can a specific cause of low back pain be identified; thus, most low back pain is termed non-specific. Low back pain is characterized by a range of biophysical, psychological, and social dimensions that impair function, societal participation, and personal financial prosperity.”

In other words, it’s complex.

Of course, there is always a need to rule out those cases where there is specific causes.

“but, this is for less than 1% of those presenting with LBP. Known causes may include vertebral fracture, axial spondyloarthritis, malignancy, infection, or cauda equine syndrome (very rare).”

So if any of these are suspected by presenting symptoms, a clinician is well advised to do testing, imaging, etc. for what are often referred to as ‘red flags’.

If these are ruled out or if you’re not suspect for these specific causes, what then?

“Most adults will have low back pain at some point.  It peaks in mid-life and is more common in women, than in men.”

“Low back pain that is accompanied by activity limitation increases with age.”

“Most episodes of low back pain are short-lasting with little or no consequence…”

“But recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences.”

It’s highest in working age groups so the effect to the workforce is impacted. People unable to work, earn income, the possibility of early retirement. “In the USA, LBP accounts for more lost workdays than any other occupational musculoskeletal condition”.

Then there’s a person’s identity. Consequences such as loss of independence, ability to fulfill expected social roles can be impacted. Common themes of worry and fear are identified, along with hopelessness, the strain on families, social withdrawal, job loss, and there’s the navigating through continual healthcare encounters.

Most studies underestimate the total costs of LBP, but the economic impact is comparable to other high-cost conditions like cardiovascular disease, cancer, mental health and autoimmune diseases.

Most cases are resolved within 6 weeks, however, there are risk factors for recurring episodes. For people with other chronic conditions like asthma, headaches, diabetes. Those with poor mental health are at increased risk, etc. As one example, a study of Canada’s population with 9909 participants, found that “pain-free individuals with depression were more likely to develop LBP within 2 years than were those people without depression”.

Lifestyle factors are also at play. Smoking, obesity and low levels of physical activity are associated, although independent associations remain uncertain.

Which brings us back to it being complex. There are multiple contributors, “including psychological factors, social, biophysical, comorbidities and pain processing mechanisms.”

We can see the complexity when there is a continual increase of those affected, an increase in our health care expenditures and by the recent opioid crisis that is literally taking people’s lives.

It also seems whatever we’ve been doing in terms of treatment doesn’t seem to be working.

Why is that and what needs to be changed?

Tune in next week… where we’ll get to the second paper, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

Note:   For those interested, all references/studies can be found in the Lancet paper, here.

It’s your life

by Jody, posted in training

Consider the ways you need to use and move your body every day.

It's your life

Depending on your life, how much you move throughout the day may be fairly limited or alternatively, you might go through a whole range of movements.

Do you work in an office? Sitting, walking, reaching, writing might be some of the things you do in a day. I suspect sitting, is a primary one. Do you work as a plumber? Your movement needs are different than the office worker. As are what a doctor, teacher, hairstylist, service worker, etc. will be, who are often on their feet much of the day.

What you need to ‘train for’ is different than what anyone else needs to ‘train for’.

What a person needs who sits at a desk all day, is different than what a parent with toddlers needs, versus what a teacher might need.

train for your life

We sometimes get into trouble when we’re doing exercises, that don’t always or altogether correlate so well to what’s actually required in our life. If you’re exercising for basic fitness and enjoyment, that’s fantastic. That in itself is an achievement. But perhaps you might consider adding more to the mix if you’re someone who also experiences pain, fatigue, etc.

This is important:

  • If you’re hitting the gym every day, building strength and stamina but suffer from low back pain because you’re also sitting in a chair for 8 hours a day, perhaps you need to train differently or add something to your training routine.
  • If you are the most amazing yogi but suffer from hip strain or other pain symptoms because during the rest of the day you’re standing on your feet, perhaps you need to look at what you’re training for.
  • If you’re out on the golf course getting your exercise and fresh air daily, but cannot ‘do, or manage’ the rest of your life, perhaps you need to do something else as well.

What happens all too often is the hour of exercise we get at the gym, yoga studio or out on the golf course doesn’t quite support all the rest of what we need to do in our day.

  • If you need to sit, train as best you can so your body can adapt for this.
  • If you need to stand, train what’s required in order to stand a lot.
  • If you are the golfer, train for whatever it is you need to do, besides golf.

But how can you do this and where to find the time?

It’s not always easy, but you can learn to build it into your day. It doesn’t always have to take another hour going to the gym, paying for a babysitter, driving through the snow. There are simple tools, you can use. Anywhere, really. That don’t take up a lot of time.

 

First, Pay Attention

by Jody, posted in Uncategorized

The Problem

Why is it you sometimes need to visit a doctor, chiro, physical therapist, massage therapist, etc. time and time again for the same problem? They adjust you, work with you in a manner that seems to provide relief but within a few weeks or months, you’re back in their office again. I have been to them all and credit is due in helping with immediate pain or to fix something.

Sometimes it works long term.

Sometimes, only temporarily.

I want to speak to the temporary fix.

Until you figure out what’s creating the problem, it will likely return.

For example, if you are overweight you understand that eating too much, moving too little or a combination of both is likely creating the problem.  You can go on different types of diets, you might do a fast, you might work out for the first two months in the New Year but if you don’t change those first two factors, over the long term your body’s weight remains the same.

You’re experiencing pain. Not able to move well. Feeling restricted perhaps in what you’re trying to do or you may be the type to just power through, get an ‘adjustment’, chow down on ibuprofen for months on end … but until you learn what’s creating the problem you won’t find long-term change or well-being.

If you suffer from an addiction, you may quit ‘the addiction’ but it will probably show up again and again unless you figure out what lies beneath.

The weight, the pain, the addiction … and so it goes …

The problem is (and we all know this) if you keep doing the same thing you end up with the same result.

Pay AttentionHowever, if you can first, pay attention you will actually learn to sense, see and feel signals your body provides that can guide you to what’s below your current level of awareness or understanding. Those signals are signposts that can lead to healing and wellness.

It’s not easy to do but with practice, information and support, we can most often, figure it out.