Low back pain & low value care

Low back pain

Non-specific low back pain remains a pretty enigmatic and widespread condition. Globally, the number of years lived with disability caused by low back pain have increased by 54% between 1990 and 2015. Low back pain is now the leading cause of global disability.

Most countries have clinical guideline which inform clinical practice. Unfortunately there is a big gap between evidence informed guidelines and the day to day treatment of patients in general practice. This gap perpetuates the ongoing delivery of what has been referred to as low value care.

Low value care

Oftentimes I see patients after they have sought the opinion and therapeutic recommendations of their GP. In many cases of non specific low back pain, this consists of diagnostic imaging (X-ray, MRI and CT) plus the widespread prescription of a variety of drug including paracetamol, non-steroidal anti-inflammatories, skeletal muscle relaxants, selective norepinephrine re-uptake inhibitors, opioids and more recently a hike in the prescription of anti-seizure medications (gabanoids, gabapentin & pregabalin).

Both imaging and drug prescription are constitute low value care and are classified as second line or adjunctive therapy.

osteopathycobargo_back pain_interventions

What type of care are you receiving? First, second-line or adjunctive? What sort of back pain is it effective for?

With regards to imaging, the evidence is insufficient to know whether MRI findings can be of use to predict the future onset, or the course, of low back pain. Importantly, no evidence exists that imaging improves patient outcomes and guidelines consistently recommend against the routine use of imaging for people with low back pain.

Number needed to treat

All patients prescribed pain medication for low back pain should understand one simple metric. This is called NNT. The number needed to treat before 50% of patients experience a 50% improvement of symptoms. As you can see from the table below, none of the medications commonly prescribed to patients experiencing low back pain are particularly effective and all pain medication has the potential to cause adverse effects – the number needed to harm (NNH). The osteopathic NNT for low back pain varies from 5-8 depending on severity. My guess is that through combining osteopathy, pain education and movement practices we dramatically lower our NNT.

osteopathycobargo_back pain_NNT

Number needed to treat (NNT) for commonly prescribed pain medications.

It has been recently established that osteopathy also has a distinct dosage response in the treatment of symptomatic (painful) musculoskeletal complaints. Osteopathic treatment effects accumulate and peak at between 2-5 treatments at which time we typically see a dramatic reduction in pain medications, a more optimistic psychological outlook and oftentimes unanticipated functional improvements on top of the symptomatic issue.

It turns out that in my own application of osteopathic principles and clinical guidelines to the treatment of non specific low back pain that I incorporate almost exclusively first line interventions including: pain education, suggestions on how to remain active, movement practices and cognitive behavioural therapy which links back to pain educations in very fruitful ways.

Overall, guidelines now place a greater emphasis on self-management, physical and psychological therapies, and some forms of complementary medicine, and less emphasis on pharmacological and surgical treatments. The reduced emphasis on pharmacological care is shown by the US guidelines, which recommends non pharmacological care as the first treatment option and reserves pharmacological care for patients for whom non pharmacological care has not worked.

osteopathycobargo_back pain_guidelines

These key messages summarise global guidelines, knowledge gaps, low value care and bright spots for the treatment of low back pain.

Consistent recommendations that underpin high value care are that individuals should be provided with advice and education about the nature of low back pain and radicular pain (e.g sciatica), reassurance that they do not have a serious disease and that symptoms will generally improve over time. Patients require encouragement to avoid excessive bed rest, to remain active and continue with usual activities including work.

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