Over 80% of individuals experience pain in their spine at some point in their lives. Back pain remains one of the most common reasons to visit the doctor, chiropractor or physiotherapist. (Power et al 2006).
In Canada, medical expenditures with respect to low back pain are estimated between $6 and $12 billion annually and the number is rising. Due to the loss of worker productivity, resultant time off work and the associated disability payments low back pain and related ailments have a significant economic impact on society (Brown et al 2005).
Although most low back pain resolves within a period of weeks to months, the natural history is not quite as simple many health care providers believe. In a recent study, over 60% of back pain sufferers had symptoms lasting longer than three months (Donelson et al 2012). The incidence of persistent low back pain and other symptoms are significant, as reported in a Canadian study conducted by Cassidy et al (2005). Over a 12-month period of observation, the one-year incidence of low back pain was 18.6% with 40.2% of those with low back pain reporting persistent symptoms, and 14.2% experiencing an aggravation of their symptoms. Of this population, 28.7% experienced a recurrence within 6 months. Other studies have put the rate of recurrence as high as 60% within one year (Pengel et al 2003). Although a recurrence of back pain is generally not associated with any increased physical problem it typically leads to further physician visits and further diagnostic testing; both costly to the Healthcare system. The more complex natural history of low back pain does not make the problem any more physically serious. It is still just minor mechanical changes that will get better and leave no permanent disability. The guidelines are accurate but the timing seems a bit off.
Access to care
Access to publicly funded health care for people experiencing low back pain is variable across Canada. Approximately 70% of patients experiencing low back pain chose not to see a health practitioner beyond their family physician or local pharmacist. One reason may be that access to some professionals, such as physiotherapists and chiropractors, is not routinely available through the publicly funded system. Patients must use their insurance benefits (if they have any) or pay out of pocket for their treatment. People experiencing low back pain who cannot or will not pay for additional treatments usually rely entirely on their family physicians to provide education, advice and treatment for their condition.
Evidence supporting back pain clinical practice guidelines (CPGs) suggests that back pain is a benign self-limiting condition (Gross, 2006). A comparative review of 17 international practice guidelines by van Tulder et al (2004) identified a number of consistent recommendations from these evidence-based guidelines including:
- reassure there is a favourable prognosis;
- advise to stay active and exercise;
- discourage of bed rest;
- prescribe medication only if necessary on an individualized basis; and
- consider spinal manipulation for pain relief.
However, the literature reviewing the use of these guidelines shows an extremely poor uptake. Many primary care physicians don’t follow the evidence based treatment guidelines (Mafi et al 2013). A recent Canadian observational study found that, despite published CPGs for the management of patients with acute mechanical lower back pain, primary care physicians were not fully applying these in their clinical practice. This study reported poor concordance with CPGs both with respect to recommended diagnostic imaging, as well as with many treatment recommendations. In addition, only 7% of primary care physicians surveyed reported that they provided educational material and reassurance to their patients (Bishop et al, 2003). Primary care physicians have difficulty managing this patient population. With little or no access to proper therapy they frequently make inappropriate surgical referrals, in the hope that the surgeon will offer help.
All a result surgeons report being overwhelmed with non-surgical consultations for which they have nothing to offer (Wai 2009). The result is an extended wait to see a surgeon that interferes with access for the few patients who do need an operation. In some cases the referrals are completely rejected and the back pain sufferer receives no attention at all. This rejection, based simply on the fact that surgery is not the proper treatment, results in unnecessary anxiety for the patient who may believe that the surgeon’s refusal to offer an opinion means there is no hope. The sufferer does not receive the simple educational information and advice they need to return to their normal activities. This leads to unnecessarily extended periods of disability and time off work.
This inappropriate care model is compounded by an overreliance on imaging rather than on clinical decision making. In Ontario over a recent 10 year period, the use of CT scans to screen for back pain increased by 199% and the use of MRI scans by 619%. Many of these were demanded by surgeons as a means of halting the flood of non-surgical referrals (You, 2009). Undue reliance on MRI as a screening investigation for back pain leads to poorer outcomes (Webster 2013). Ordering an MRI may do more harm than good. Recent data has found implementation of an alternate system, where patients are treated for back and back-related leg pain based on the clinical findings of a health care practitioner trained in a syndrome, pattern of pain approach, improves the appropriate utilization of further investigations and results in significant net savings (Hall et al. 2009; Wilgenbusch CS et al. 2014).
This web site has been designed to provide all patients with the basic information about low back and back-related leg pain. The information provided reflects best evidence and supports a framework for active participation and rapid return to recovery. We realize that some patients will have ongoing symptoms but the concepts for the management of low back pain remain the same whether symptoms are from a first attack or part of a recurring problem.
This web site is not intended to replace instructions from any health professional providing information or treatment for their patients.
This web site will be periodically expanded to include further evidence based information about the treatment of low back pain for health practitioners.