During the past 25 years, the incidence and prevalence of low back pain has remained constant, while costs have increased, even after the revolution of understanding of low back pain, Max Zusman, DipPT, GradDipHlthSc, MAppSc, of Curtin University in Perth, WA, Australia, wrote in a study recently published in the Journal of Multidisciplinary Healthcare. An overwhelming majority of cases also had no “red flag” basis. Zusman offered an explanation for the increasing costs of treatment for low back pain, which he said has less to do with the patients and more to do with the beliefs and behaviors of health care professionals.

“Recent figures show that there has been no change in the upward trend of direct and indirect costs for the largely benign symptom of low back pain in Western societies. Moreover, in recent years, several large-scale education programs that aim to bring knowledge of the public — including general practitioners — more in line with evidence-based best practice were carried out in different countries,” Zusman wrote. “The hope was that the information imparted would change beliefs, ie, dysfunctional patient behavior and biomedical practice on the part of clinicians.”

However, these programs had no influence in three of four countries due to difficulty in altering beliefs among patients that low back pain has a structural mechanical cause, which continues to be reinforced by their providers.

Belief reinforcement

According to Zusman, low back pain was previously viewed as being the result of tissue pathology involving structural, anatomical and biomechanical factors (SAB model) and was often treated surgically or with lengthy deconditioning, pain-dictated bed rest. Alternative providers favored noninvasive fault correction with the SAB model. However, the SAB model was easily misinterpreted and resulted in unacceptable failure rates, iatrogenic events and highly increased costs, Zusman said. Further increased insight into the mechanisms of pain and the evolution of the biopsychosocial model of pain followed.




Best practice guidelines for diagnosis and treatment of low back pain were released favoring limited total rest and gradual resumption of everyday activities despite major pain. The guidelines also recommended only highly selective invasive treatment and limited conservative treatment. Although providers were updated on these changes, they did not necessarily follow the new guidelines, while the public was left unaware of this change in thinking, Zusman wrote.

“While the orthodox medical profession in general may have noted the evidence, the uninformed lay public remains largely unaware of this calamitous health care experience and paradigm shift. Or what they have been told is inconsistent with their clinical experience,” Zusman wrote. “Large-scale public education programs, while evidently of some limited benefit, are difficult to organize and can be very expensive. Nor is it clear regarding the extent and how lasting any effect of such programs might be. Although people harbor their own intrinsic fear of invasive treatment, the broader lay public has no convincing reason to abandon the SAB basis for low back pain.”

Patient education

Although low back pain could be cause for serious concern, patients need to be aware of “non-red flag” back pain caused by everyday incidences. Although this kind of back pain can be severe, it is generally self-limiting and can be caused by acute strain, routine physical activity, osteoarthritis and sustained or repeated abnormal posture or movement.

“Patients should be encouraged to welcome the fact that their nonspecific pain problem is not SAB-based,” Zusman stated. “If this were the case, the pain would not be modifiable in any clinically relevant way using existing hands-on treatment, and patients generally do not relish the idea of invasive procedures. Beginning with the hands-on provider, this point needs to be driven home by any means available in educational programs funded by the public or otherwise in the future.”

To help change the belief that all back pain is cause for major concern, patients should receive an explanation from their physician for why they are experiencing low back pain. Without the appropriate validation from their physician, Zusman said patients may start to believe that their physician is either incompetent or that “they may be harboring some hidden sinister pathology that requires urgent investigation.”

Although there is still need for further research on current therapy for low back pain, evidence-based public education programs and clinical best practice will need to be supported by the clinical 
experience of patients, which is undermined by providers as well as SAB-treatment, according to Zusman.

“There are probably several understandable reasons why clinicians do not always follow clinical best practice guidelines. With hands-on providers, it is simply because these guidelines are fundamentally incompatible with their professional raison d’être,” Zusman concluded. “How hands-on clinicians might go about conveying current evidence-based messages to their patients while retaining at least the core of their clinical methods is for them to decide. However, the time to decide has definitely arrived.” — by Casey Murphy

For more information:
Zusman M. J Multidiscip Healthc. 2013;6:197-204.

Disclosure: Zusman has no relevant financial disclosures.

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