by Matthew Bennett
Many people with low back pain get the wrong care, causing harm to millions across the world and wasting valuable health care resources. Those are not my words but the opening to a recently published article by eminent researchers1. Why is this still happening? We know what works for back pain but unproven, unhelpful and unnecessary care is routine.
Four years ago, I was elected as a trustee to a national campaign group to redress this. We fight for people with back pain to get the best care. It is not only back pain sufferers who get poor care, of course, so we campaign for all musculoskeletal (MSK) conditions. The group is called the Arthritis and Musculoskeletal Alliance – or ARMA for short.
ARMA is 40 or so patient and professional bodies who have banded together with a common cause. Chiropractors, doctors, physio’s, osteopaths, podiatrists and a wide variety of patient pressure groups speak as one. Our vision is to promote MSK health of the population throughout life and for everyone to receive appropriate, high-quality treatment promptly. We believe that everyone should get the right care, fast.
We organise conferences, meet ministers and lobby NHS England. We have created a single voice for all those with bone and joint problems, including back pain. We also help local NHS organisations develop local plans to understand what is needed to deliver evidence-based, cost-effective services for good MSK health, and to help those looking to improve services.
We also lobby on the world stage. ARMA is part of an international network of similar organisations in other countries. I have been to the World Health Assembly at the World Health Organisation in Geneva. Although I was a small voice amongst the thousands of delegates, I was able to make a case for better MSK services in meetings and to individuals.
It was a privilege to meet Dame Sally Davies, the then Chief Medical Officer of the UK. We talked about her project on antibiotic resistance and I told her about the need for better back care. I tried to buttonhole Jeremy Hunt too but he ignored me!
It seems strange to mention MSK problems like back pain in the middle of a pandemic which is taking hundreds of thousands of lives around the world and affecting us all. It is, however, essential to keep on talking about MSK problems because of their impact. Other health conditions always get more press, more political attention and more research cash and we are seeking to redress this.
Heart disease, obesity, cancer and Alzheimer’s are big problems for sure but back pain is the single most significant cause of disability worldwide1. It affects all age groups from children to the elderly and can be profoundly disabling to some. Someone with back pain can’t exercise as much as they would like so conditions like obesity and heart disease are made worse. People with chronic back pain also suffer from more mental health problems. Depression and social isolation are worse in people with long-term joint pain.
Disability from low back pain is highest in working-age groups worldwide. It is the most frequent cause of medically certified sick leave and early retirement in Europe and accounts for more lost workdays than any other musculoskeletal condition. It is time to get serious about back pain.
What about social inequality? Here, back pain too plays a significant role. Disabling low back pain is more common in lower socioeconomic groups and in those with lower educational attainment. Those with back problems are more likely to be in income poverty compared to those without chronic health problems and this reinforces the cycle of poverty and inequality.
It is easy to see the effects on our friends and family. Most of us know someone who gets episodes of disabling back pain. It is tempting to think that this is a first-world problem with inactivity and our sedentary lifestyle to blame. But this would be inaccurate. In a study of 500 farmers in rural Nigeria, more than half had reduced their farming workload and one in three had been absent from work in the past year because of low back pain. It’s everywhere and it is getting worse.
In the United States, the highest healthcare cost of any condition is for back and neck pain at $135 billion. It has gone up 7% a year for the last 20 years and shows no sign of slowing down. Other MSK conditions came in at number two and diabetes third on the spending spree. Heart disease was lower at a paltry $90 billion.
Despite this tidal wave of back pain suffering around the world, many are not getting the right care. The authors of this recent review concluded that despite their 2018 articles in the prestigious medical journal the Lancet, their call for evidence-based back care has mostly gone unnoticed. Not here.
Here at Sundial, we studied the findings and reviewed our care. Fortunately, we did not have to adjust our care that much. As you might hope and expect, as back experts, we were following the best evidence already. So what is the best care for back pain: stay active, avoid bed rest, the option of spinal manipulation, and/or simple painkillers.
In part two of this series, I will look at the unproven and harmful approaches to back pain that are prevalent everywhere.