If you’re reading this, then you already know.
Low Back Pain (LBP) is a big issue. A really big issue.
It is the leading cause of disability globally, ahead of 290 conditions and is responsible for 83 million years lived with disability in 2010 (Ref). I gravitate towards this topic because, well, it’s pretty damn important. It is also a problem that our current system does not seem to be impacting; incidence and prevalence rates have stayed almost static for the past 25 years. By the numbers, the economic impact of LBP is staggering.
A systematic review by Dagenais, Caro and Haldeman of 21 large economic impact studies from the period of 1997 – 2007 is great reading (Ref):
Australia, in 2001, incurred direct costs of just over $1 billion AUD as a result of LBP investigation and treatment.
This direct cost is dwarfed by indirect costs incurred by Australia due to LBP of $8 billion AUD. Indirect costs include such things as absenteeism (sick leave and time off work), presenteeism (loss of productivity at work) the loss of earnings, claims paid and litigation.
This makes Australia incur a total cost for LBP of $9 billion AUD annually. Now to put this into perspective, the UK has a population almost 3 times the size of ours and has a total cost estimate of £12 billion. We pay $474 AUD per person and the UK pay £209 and if my trusty converter app is ‘on the money’ then the Australian system is incurring around $100 AUD extra per person than the Brits.
To put this into perspective amongst other conditions, when you compare LBP to a chronic 'pandemic' like diabetes, once again the economics involved are staggering. Diabetes, although very costly per person, is associated with a burden in the region of $6 billion annually (Ref).
The burden of LBP is not happening in clinical treatment rooms, but with everything else that goes on outside of the consult. This means the role of the treatment provider, whilst still integral, actually pails in comparison to the role of the case manager, the injury management advisor, the boss, the bureaucrat, the politician that are major stakeholders in this 'non-clinical' system. As treatment providers, it is time we accept this fact and make steps to incorporate our other stakeholders.
Of the direct costs of LBP, a general picture of the utilisation of treatment providers is another telling story. Walker et al in 2004 (Ref) performed a cohort study of 1913 adults in varying stages of LBP and were able to gain a real point-prevalence of the population, who were pretty representative of the average Aussie. They found:
GPs were most utilised in managing LBP (22.4%)
Chiropractors were second-most utilised in LBP (19.3%)
Massage therapists were third (14.9%) and physiotherapists were a lowly fourth (13.4%) in this study.
When broken down for medical costs incurred, chiropractic accounts for 20% of all costs and physiotherapy accounts for 14% (Ref). Read what you will into this, but as a physiotherapist, I read that it is simultaneously insulting that we don’t get used as much as chiropractors but also humbling that we may actually end up costing more. Once again, it is a sobering fact, that we may have to accept in order to do something about this burden. We physiotherapists are a small fish in a big pond and may have to start to reach outside of our own boundaries.
Now GPs manage the bulk of LBP incidence, that would seem pretty obvious, and I’m getting to their performance soon, but what is striking to me is that 55.5% of people did not seek treatment at all. For me, this is surprising, as I assumed the scope of people not entering ‘the system’ to be a much lower proportion of the populace, not a number over 40%. At the same time it can provide hope that, as practitioners, there may be more room for impact than I originally thought. But we are still left with the majority of cases being ‘managed’ by pretty much public health policy.
So, to those GPs that manage so many of our patients.. Another cohort survey by Williams et al in 2010 has some good insight into what our GP friends are doing (Ref). Their data is from 2001 to 2008 – so bear in mind, this is fairly recent stuff. Just a warning, it’s ugly. Of 6296 encounters involving new LBP presentations:
Nearly 20% (19.6%) of LBP cases received opioid medication
Only 20.5% of people were provided with advice and education
Imaging was requested in a quarter of patients
Encounters were tabulated before and after the NHMRC guidelines on LBP management in 2005; the results are made even uglier because these guidelines didn’t change any of the proportions significantly. In fact, providing advice and education was higher (24.7%) before the release of the guidelines than afterwards. I mean, do GPs have ODD or what??
So a tiny proportion of LBP burden comes from direct medical costs, instead the burden comes from all of the associated indirect costs (and the policies that go along with that). Most LBP cases don't actually even seek treatment and the cases that do seek treatment are generally managed by GPs that don't seem to follow any recommended guidelines. If you are a physiotherapist and reading this, I hope you are humbled by how little impact your role actually becomes in the grand scheme of things. Minuscule. I can say that because I am a physiotherapist...
The salient point for me here, is not GP bashing, I love GPs; they are the bedrock of our health system and do not get enough love for the role they play. It's not even chiropractic bashing! No, the salient points are that if well-meaning, educated professionals can’t follow advice, then we can bet that:
Unscrupulous health professionals certainly won’t follow best-practice guidelines of providing gold-standard care
The general public (on a public health scale) won’t be receiving any legitimately helpful information that will reduce a pain burden any time soon.
The system will perpetuate and provide the same results it has for the past 25 years. Nihilist? Sure.
So we can’t just sit here and pretend it isn’t happening. The system is broken and we need to stand up for what we know works; providing simple advice and remaining moving. And seeing as the majority of people don’t even enter into treatment, we may need to start to think a little bigger than our clinical confines. Although, the Australian Physiotherapy Association’s (APA) new ambiguous and ‘sexy’ campaign espousing #choosephysio is great, what we really need is a legitimate public health campaign. It has been done in Victoria, at the turn of the century, and it seems to work to reduce low back claim rate, costs and importantly positively shifting popular ‘unhelpful’ beliefs about LBP (Ref). It isn’t perfect, but it was a start! Why has this not been replicated? Why has this only been confined to one state in Australia?
Whilst there is an incredible amount of complexity involved in this issue and public health education won’t be enough, it would be a start in the absence of widespread policy change. The all-important compensable system, which in itself incurs a greater risk for disability from LBP (Ref), is where I spend my days and there is a drastic lack of top-down policy encouraging proactive approaches to this problem. We are suffering from a real lack of evidence at the primary prevention level, which makes the main avenue to implement any policy change - Workers Compensation - an incredibly reactive context and a sad state of affairs (Ref, Ref). Protective legislation for employees should be centred around ensuring workers are 'work ready' and would force employers into a preventative focus. There is really good evidence for proactive approaches to reduce sick leave, in this Cochrane review (here) exercise performed on a prophylactic basis were shown to have a positive effect on reducing the number and prolonging the time to recurrence of LBP. Health and Wellbeing programs would ensure a lot of the contributors to LBP are actively addressed before becoming larger issues. But to change this system, we do first need evidence of the efficacy of primary prevention programs, and to do this we actually need primary prevention programs.
LBP might just be the emergent health condition of our time; it seems to be the end of the road for all of the failings of today's society. LBP might just be the emergent health condition of our time; it seems to be the end of the road for all of the failings of today's society. Think workplace stress, anxiety, depression, obesity, metabolic risk, sleep debt, sedentariness; they all have strong links to LBP. It is the straw that breaks the camel's back; people enter into a 'pain state' but in reality they have travelled a long road to get there and the contributors along the way all need some attention. Let's begin some truly innovative practices, outside of our clinic doors and ensure the unseen patient doesn't become our patient. Let's co-ordinate with our chiropractic brethren, let's educate GPs, let's educate our workplaces, let's educate our injury management staff and case managers, let's push for a really solid public health campaign and worker's compensation legislation that encourages proactive - not reactive - policy. So for every health professional (and non-health professional) that that is reading this, low back pain is not just your business but everybody's business, let's actually move the needle amongst this hulking condition that has become the most burdensome condition we have today.