The hard truth about back pain: dont rely on drugs, scans or quick fixes | Ann Robinson

Most treatment is wasteful, wanton and wrong, tells the Lancet. The key is to try to keep walking and work, tells the GP Ann Robinson

Back pain is the biggest cause of disability globally, and most of us will have at least one nasty bout of it. But treatment is often wasteful, wanton and wrong,according to a series of papers in the Lancet.” Worldwide, overuse of inappropriate tests and therapies such as imaging, opioids and surgery means patients are not receiving the right care, and resources are wasted ,” it says.

It’s perfectly understandable to want a quick-fix solution to construct the pain go forth and maybe a scan to set your intellect at rest. But there isn’t a reliable instant answer. Scan don’t construct you better, and painkillers can be harmful. The vast majority of low back ache is musculoskeletal– caused by damage caused to ligaments, joints and muscles surrounding the spine. A tiny percentage is due to a serious or dangerous underlying cause that it was necessary to specific diagnosis and intervention- such as cancer, infection or a fracture.

An underlying cause is more likely if you have so-called red-flag symptoms; previous or current diagnosis of cancer, fever, unexplained weight loss and sweats, night ache, ache in the middle of your back rather than lower, inability to stand, urinate or open your bowels, or severe and unremitting pain that is getting worse.

The good news is that if your backache is musculoskeletal- and it usually is- 90% of cases will be better within six weeks. And that is irrespective of what you do. There’s no good evidence that interventions, ranging from Tens machines( which use a mild electric current ), acupuncture, physio, osteopathy and chiropractic to epidural injections and surgery, significantly affect the outcome. Prolonged bed rest- still advocated in some countries- is positively dangerous, as it can cause blood clotting( thrombosis) and builds recovery from back ache less likely.

The
‘ The evidence may not be great but it’s cheap, safe and happens to work for me .’ A Tens machine. Photograph: Alamy Stock Photo

It’s seducing to want a scan or special investigations if you develop back ache. But scans don’t correlate well with symptoms; you can have a dire-looking scan with no symptoms or a somewhat normal-looking one with dreadful ache. A scan is useful for surgeons if you need an operation, and other imaging is important if an underlying fracture is suspected. If your back pain is associated with an underlying inflammatory condition like Crohn’s, ulcerative colitis or psoriasis, you will need investigation and referral to a rheumatologist.

The key to recovery is to try to keep walking and run. Different approaches help different people; it’s good to find the least risky option that suits you. My own favourite is a Tens machine: the evidence may not be great, but it’s cheap, safe, and happens to work for me.

Painkillers can be useful in the short term, if that’s the only way you can keep moving. There are two main groups of effective analgesics, and they both come with health warnings: non-steroidal anti-inflammatories, ( NSAID ) such as ibuprofen, and opioids such as tramadol. There is already an epidemic of opioid overuse and addiction in the US, with Europe and lower-income countries catching up fast. NSAIDs are less addictive but can cause heart, kidney and intestine injury if used for more than a few days at a time.

Prof Nadine Foster of Keele University, one of the authors of this series of newspapers, says:” In many countries, analgesics that have restriction positive effect are routinely prescribed for low back ache, with very little emphasis on interventions that are evidence-based, such as workouts. As lower-income countries respond to this rapidly rising cause of people with disabilities, it is critical that they avoid the waste that these misguided practices necessitate .”

One in three people who has an episode of low back ache will have a recurrence in the following year. So it is important to look at adaptations to the workplace, avoiding heavy lifting and concentrate on core muscle strengthening with pilates, swimming and some types of yoga once you recover from the acute attack.

Prof Jan Hartvigsen, of the University of Southern Denmark, who also contributed to the Lancet series, tells:” Millions of people across the world are getting the incorrect care for low back ache. Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interest, and fiscal and professional incentives that maintain the status quo … Funders should pay merely for high-value care, stop funding ineffective or harmful testing and therapies, and importantly intensify research into prevention, better tests and better treatments .”

He’s right, of course, but there is no phase withdrawing funding without any explain. Healthcare professionals need to take the time to explain to patients that it’s not vindictive cost-cutting that is behind the restriction of access to scans and drugs. It’s in everyone’s best interests that we stop seeking bad medicine and invest in detecting better and safer solutions to this global problem, which is likely to affect all of us sooner or later.

* Ann Robinson is a GP

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