The Lancet Series call to action to reduce low value care for low back pain: an update

Abstract

1. Introduction The 2018 Lancet Low Back Pain Series, comprising 3 papers written by 31 authors from disparate disciplines and 12 different countries, raised unprecedented awareness of the rising global burden of low back pain partly attributable to poor quality health care.12,30,44 Many people with low back pain get the wrong care, causing harm to millions across the world and wasting valuable health care resources. Based upon an up-to-date, evidence-based synthesis, the series described current guideline recommended care of low back pain, and new strategies that show promise, but require further testing, to reduce low value care. We also proposed a series of actions needed to reverse the alarming global rise in low back pain disability. A better understanding of low back pain in different cultures and changes to the way care for low back pain is delivered and the way clinicians are reimbursed are key to reversing this problem. To reach all relevant stakeholders, we devised a well-planned and thorough media strategy to facilitate promotion of the series. This included not only Lancet staples such as a Lancet social media card, structured press release, and Lancet podcast distributed to about 2000 journalists but also email banners, country media focal points who could provide country-specific information, a set of global key messages that were modified for country-level use, a twitter hashtag of the series, #LowBackPain, and a schedule of suggested tweets to be used by authors over the 48 hours before and after the publication of the series. The series was also made free to download (see https://www.thelancet.com/series/low-back-pain). The success of this approach is evident by the unprecedented media coverage it received with all 3 articles achieving Altmetric scores in the 99th percentile. There was media coverage in at least 17 countries including wall-to-wall coverage in the United Kingdom, Australia, and Denmark. Furthermore, interest in The Lancet Low Back Pain Series has persisted as evident by continued attention from major media outlets. For example, The Economist published an article entitled “Back pain is a massive problem which is badly treated” on 18 Jan 2020,17 accompanied by a “Leader” (editorial opinion) on the topic. This review, invited to coincide with a plenary at the 2020 World Congress on Pain, outlines and discusses some of the main messages from The Lancet Low Back Pain Series, with a focus on pertinent positive and negative developments since it was published. 2. Low back pain is still the number one cause of disability in the world Low back pain is a common problem affecting all age groups from children to the elderly. While highly disabling in only a very small proportion of those affected, its high prevalence means that in 2015, low back pain was responsible for 60·1 million disability-adjusted life-years; a 54% increase since 1990, with the biggest increase seen in low-income and middle-income countries.44 In the latest data from the Global Burden of Disease Project published in 2017, the global point prevalence of low back pain was 7.8%, meaning that 577 million people are affected at any one time.38,37 Focusing on Africa, a 2018 systematic review (65 studies) found the lifetime, annual, and point prevalence of low back pain was 47% (95% confidence interval [CI] 37-58), 57% (95% CI 51-63) and 39% (95% CI 30-47), respectively, comparable or higher than what has been observed in population studies in high income countries.67 Low back pain remains the leading global cause of disability overall and in both males and females, accounting for 7.6% or 42.5 million years lived with disability across all age groups, topping the list of causes of disability in 126 of 195 countries and territories in 2017.38 It is also very costly. For example, a recent study estimated that US$134.5 billion was spent on health care for low back and neck pain in 2016 in the United States, the most out of 154 conditions studied, and this had increased by 6.7% annually between 1996 and 2016.25 As we outlined in the first article in The Lancet Series,44 disability from low back pain is highest in working age groups worldwide. It is the commonest cause of medically certified sick leave and early retirement in Europe4 and accounts for more lost workdays than any other musculoskeletal condition in the United States.87 It also hampers productivity growth. For example, Schofield et al. demonstrated that back pain is the most common health condition forcing older Australians to retire involuntarily.75 Both the development of disabling low back pain, as well as early retirement due to chronic symptoms, is overrepresented among people with lower socioeconomic status and education attainment,59,80 The condition contributes to the cycle of poverty and social inequality. In Australia, regardless of labour force participation, those with back problems are more likely to be in income poverty compared to those without chronic health problems.76 Compared to those with back problems who remain in the work force, those who are not working due to back problems are 90% more likely to be in income poverty.76 In poorer regions of the world, the contribution of disabling low back pain to the poverty cycle is worse because of the greater prevalence of informal employment, limited possibilities for job modification, absent or poorly monitored occupational musculoskeletal health policies, and the lack of social support systems. For example, in a study of 500 farmers in rural Nigeria, more than half had reduced their farming workload and one in 3 had been absent from work in the past year because of low back pain.28 An ethnographic study of villagers in Botswana found that low back pain as well as other musculoskeletal symptoms results in both economic and subsistence consequences.64 For the vast majority of people with low back pain, it is currently not possible to accurately identify specific causes or nociceptive sources. Risk factors and triggers for episodes of nonspecific low back pain include previous episodes of back pain, the presence of other chronic conditions such as asthma, headache, and diabetes, poor mental health (including psychological distress and depression), genetic influences, as well as awkward postures, lifting, bending and heavy manual tasks, and being tired or being distracted during an activity.44 Smoking, obesity, and low levels of physical activity, all related to poorer general health, are also associated with occurrence of low back pain episodes.77–93 Low back pain is a chronic condition with a variable course characterised by often recurrent but transient episodes of low back pain.44 Across all categories of low back pain, there are multiple factors that can contribute to the persistence of disabling pain including genetic, biophysical, psychological, and social factors and coexisting comorbidities. Many of these prognostic factors are shared with other regional musculoskeletal conditions,41 and co-occurrence of low back pain with pain at other sites is also common. How pain is processed, experienced, and understood has a central role in the development and maintenance of disabling pain.60 Studies of Latino-American immigrants in the United States and of Australian Aboriginals also found that exposure to a more biomedical interpretation of low back pain increased disability by shifting previous beliefs that back pain is a benign and normal part of everyday life towards back pain being a medical condition that requires attention and treatment.13,62 3. Many patients with low back pain are still receiving the wrong care A 2018 systematic review that included 14 studies mostly from the United States (6 studies), United Kingdom (3 studies), and other high-income countries found that overall more than 50% of people with low back pain seek care annually and 30% have sought care within the past month.5 Proportions were similar irrespective of whether the study included workers or the general population, but rates did vary by setting, eg, 67% (95% CI 50-84) in the United States vs 48% (95% CI 33-63) in Europe. These data are very concerning as much of modern back pain care is ineffective and some care is harmful. The surge in global low-value care for low back pain that includes presentations to emergency departments, liberal use of diagnostic imaging, opioids, spinal injections, and surgery has also led to skyrocketing medical and human costs. A 2012 study in a US Veterans Affairs Health Care facility found that 59% of outpatient lumbar spine scans were inappropriate.3 This suggests that unnecessary lumbar spine magnetic resonance imaging scans for people not suspected of having a serious condition cost $US300 million per year in the United States. This is supported by a 2019 systematic review (14 studies) which found evidence that imaging is associated with higher medical costs, increased health care utilization and more work absence compared with nonimaged groups.61 Despite little evidence to support its use for most back conditions,43 and a 20% failure rate,91 another US study estimated that $US12.8billion was spent on spinal fusion surgery in 2011, the highest aggregate hospital costs of any surgical procedure.92 As outlined in the second article in The Lancet Series, the global gap between evidence and practice relates to both overuse of low-value care as well as underuse of high-value care and is apparent across all income settings.30 We highlighted the discordance between 10, highly consistent, international guideline recommendations and current clinical practice, by providing examples from both high-income and low-income or middle-income settings. Although most is known about the size and nature of the evidence-practice gaps in high-income countries, and particularly in the United States due to a number of large robust studies, emerging evidence from low-income and middle-income countries indicates similar problems in these settings. A 2020 population study in Central Ethiopia (N = 1812) found that 30% (95% CI 27.9-33.2) of the population had sought health care for low back pain in the previous year.6 Of these 77% were treated with injected medications. There was a strong relationship between educational level and receiving back pain treatment, with those with a degree more likely to receive treatment compared to people with no education (adjusted proportion ratio = 1.68 [95% CI 1.44-1.99]). Surprisingly and unexplained, health care use was higher in rural compared with urban populations (adjusted proportion ratio = 1.69 [95% CI 1.44-1.99]). A 2019 systematic review (6 studies) found that management pathways in African countries typically favour treatment approaches with ineffective passive treatment modalities.1 The authors identify a need for culturally sensitive and context-specific biopsychosocial interventions. A 2020 survey of physiotherapists in Nigeria found that although 79% were aware of clinical practice guidelines for treatment of low back pain, just 28% reported adhering to these when treating people with low back pain.2 A 2018 qualitative study of unconventional healers in rural Nigeria found that passive treatments linked to a spiritual or biomedical understanding were typically advised.51 At the other end of the health care spectrum, invasive non–evidence-based treatments, such as sacroiliac joint injections, are being offered to some people with low back pain in Ghana.81 Major international clinical guidelines have moved away from medicalized management of low back pain and prioritized nonpharmacological approaches as first line care.82,83 However, a recent consensus statement for the assessment and management of chronic nonspecific low back pain by the Chinese Association for the Study of Pain recommended pharmacological therapy as first-line treatment and continue to recommend medicines and interventional therapies that have either been proven to be ineffective and where harms may outweigh benefits, or are of unknown efficacy.63 With increasing development and improved educational attainment in low-income and middle-income countries, there is a real risk that there will be massive increases in inappropriate care for low back pain and increased disability. 3.1. Opioids and gabapentinoids We highlighted in The Lancet Series one of the most disastrous examples of harmful medical care for low back pain—prescription opioids. We identified extreme overuse in some (eg, United States) but not all (eg, Japan) high-income countries, but lower income countries appeared to have very low rates of use.30 Now, a Los Angeles Times investigation has revealed that aggressive marketing appears to be leading to new epidemics of opioid prescribing in low-income and middle-income countries.73 There is also evidence of illicit trade, particularly of the drug tramadol in Africa.86 For example, in Egypt, about 100,000 people are addicted to opioids, with half of them using tramadol, while two-thirds of people treated for addiction in Egypt's state institutions are addicted to Tramadol.86 We also now have more evidence that adding opioids to a nonsteroidal anti-inflammatory drug not for people with low back This was most demonstrated in a series of by et patients to the emergency with low back The also that an opioid strategy was not more than a strategy in patients with chronic low back pain to pain from or while it was also more likely to cause Although the high rates of opioid prescribing are now to in some high-income countries such as the United and the United opioid is being for or used with In the number of for and were 30% and respectively, in the 12 to 2019 than the 12 to In one study of patients to a pain in the of were an over half of were also on while of those on therapy were on high of both only the evidence not support use of gabapentinoids for nonspecific low back pain studies in both and have reported an increased number of associated with opioid and This increase in prescribing may be by a that these are with some authors the that gabapentinoids are in the general This is of the of the US where in an article in the entitled of that it was to addiction in people using opioids for chronic pain on very limited The World Health guidelines to opioid use, now that had been by but therapies for low back and In high-income countries, there has been an increased of the use of It is now possible to these on in some for Health and Care did not any of to low back pain and their use for chronic pain in the for an in the United Kingdom, a in 2019 there was evidence that had a for However, another from the that evidence now that is not is well by the human and no health from Studies use of and opioids among people with chronic A study found had greater pain and lower in pain, and there was no evidence it reduced pain or or an There is an need to and about and to the aggressive marketing approaches for that the opioid a new prescribing may be medicines such as or lumbar or to However, there is only a relationship between and the of low back pain (eg, is in 54% of those with low back pain and of those who are which means that these are to low back pain for most A 2019 systematic review of studies identified studies on clinical from treatments for low back However, these were in of both and and only one = was The authors reported small of over with no The current evidence is to support the use of for people with low back new therapies or treatment approaches of therapies such as and sacroiliac joint have been but it is to these only are the had major For example, the to of its 3 and did not on the the authors that the therapy had clinical which points to review and lack of Although the of sacroiliac joint fusion results fusion over the absence of a and lack of may the observed published have also to the results of the of therapies such as as treatment of low back pain in people with and as treatment of low back pain of the to which upon physical and to with physical also to the positive observed in the Back This the of in the and different health care settings. A is that often not as a high and can be There has been aggressive promotion of low back pain as a of nonspecific low back the of the most used to pain, has been found to be In there is now greater that medicines are not for low back pain but are associated with pain education is particularly among but a recent it was no more than education in patients receiving first-line care to of spinal of the spent on low back pain is and better level and are needed is being on a global to the rising burden of low back The and burden of now outweigh that of and in most when strategies for and management of only half of for and musculoskeletal health and low back pain, those being the most The Lancet Series identified that included of practice, the of clinical health and occupational care, changes to and and health and we also that most were not for as the evidence them was to reduce overuse of imaging for low back pain, a major of and have not with much success to imaging rates is and strategies be towards the and health care imaging to a for their clinicians imaging because of beliefs and from of and and health continue to liberal to imaging because of and from Global to health care and such as are imaging for low back of these have not been well A 2019 of a strategy to reduce general for and scans that was by the Australian in reported a in lumbar spine scans over that to a cost to the of Based upon an estimated cost of the which was delivered to general of all general in the cost per on were and it is not known whether or not there was any of scans by medical for magnetic resonance of strategies to better clinical management and for people with back pain have In a found that a strategy that general to provide evidence-based education and and early and management of to did not compared with However, it did general with low back pain and further are needed to whether or not it reduce unnecessary health care use, increase work participation, and economic A study of a spine care that spine care recommendations in one care practice care but not another care reported a in health care mostly attributable to reduced spine surgery utilization was also reduced while manual care costs were have been made to provide on upon by evidence for in the For example, in the demonstrated that physiotherapists in a of and to people care for back pain was using a of and an in a providing support for a In the Back of a structured education and was found to be to and are being monitored a clinical in a Although there is no evidence that these approaches are to current care, are being on the that of education and may be by clinicians being about to these strategies in their practice health systems. studies have clinical pathways for low back pain and other musculoskeletal such as or and management of patients on Although the results have been with to reduced and and with the care there is still evidence from high quality studies that are compared with countries the Global Care to for of evidence-based care for spine pain and disability The includes a and and outlines for is currently being sought for studies that can the and of this in and low-income In of the evidence that to the risk of of low back pain, it will be particularly to the of the in low-income and middle-income and the of and will be the of the for The of The Lancet Low Back Pain Series proposed a set of actions to the major global of disabling low back We the need to harmful while to and health care for proposed actions to these are outlined in 1. Of the actions we these were the that as the most during presentations and of the is also likely to reduce the overall burden of musculoskeletal conditions that attributable to low back pain due to the shared in biopsychosocial risk for pain and low back pain may have limited on overall health for the proposed actions to care for low back of The Lancet Series authors and was in with the for Back and Pain in Care in in We invited to provide about any media including social media any health or were aware of in their countries publication of the on to the by the series to reduce the burden of low back pain on a global and A of is being as a A at the to reach consensus on a to an data set that could be to status and changes in health care and health for people with low back To what is currently being at a global a review of low back is The Lancet Low Back Pain Series outlined a way to the increasing and of disabling low back As a it media attention and to but attention now be towards with and and to identify and While will and in different countries will be to these of interest statement is or on multiple previous and current from and in and has received for at from the the is an on the which received at no cost from is or on multiple previous and current from the for Health and is a on by the Australian is an has received for at from the the is a and of that data for health is part of an with by the related to to work is a on studies receiving support in from has for from for in was an of the series, and a of the for which received a is or on multiple previous and current from and in and have been when has been invited at and has received for of and is or on multiple previous and current from and in and has received for at from the the is an on the which received at no cost from

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