Low Back Pain Epidemic

Low back pain is becoming an epidemic. Low back pain is the second leading reason for visiting a physician, only after upper respiratory complaints.(1) According to a study published in Spine in 1998, an estimated $25 billion dollars a year is spent on the treatment of low back pain. (2) That is approximately three times the cost of cancer.

Numbers according to Occupational Low Back Pain. New York: Praeger, 1984:107 The breakdown of the costs is staggering. Disabilities comprise 67% of all costs, and 33% goes to medical expenses. A more complete breakdown is listed in box 1.(3) With disabilities making up a significant percentage of the costs it is apparent that there is a breakdown in the management of low back pain cases. So what are we to do about this excessive expense? Even though only a small percentage of individuals with acute low back pain develop chronic, unremitting pain and disability, this group demands our attention.(4)

What are evidence-based practices telling us on treating this small percentage? There are 7 R’s that are easy to remember and apply into practice.

1. Rule out “red flags” such as cancer, neurological deficits, cada equine, etc.

2. Reassurance that no serious disease is present and that improvement is likely to begin rapidly (within a few weeks).

3. Reactivation advice that normal activities can be resumed (walk, swim, bike, etc.) and education about simple activity modifications to reduce biomechanical strain.

4. Relieve pain with medication or manipulation.

5. Re-evaluation of those entering the sub acute phase for structural, functional or psychosocial pathology.

6. Rehabilitate/recondition/re-educate muscles using low load core stabilizing exercises.

7. Refer for specialist tests or treatments when indicated.

The Seven R’s taken from Rehabilitation of the Spine by Liebenson.

A patient of mine came into the office complaining of sharp pain in his spine and radiating pain down his leg on a Friday. He had a back surgery three years prior to this incident. With precaution I took a thorough history, and exam. Then, I proceeded to treat him. I suggested that he rest over the weekend and then to move about like normal on Monday. He presented to my office Monday stating he was feeling much better. I cautioned him on intense exercises demonstrated to him some low load exercises that would spare his spine. He returned to work and to exercising. I monitored his recovery, and he was back doing things he could shortly after this incident. Low back pain for most people is something that must be maintained almost like a car. The patient must learn ways to control pain, and when needed obtain treatment that can keep them pain free.

Deyo performed a controlled clinical trial that compared 2 days of bed rest against 2 weeks of bed rest and concluded that a shorter period of bed rest was as effective as a longer one. The negative effects associated with prolonged immobilization were not seen with brief rest. A more recent study showed that four days of bed rest lead to more sick leave than advice to stay active.

The Cochrane Review of advice as a single treatment for low back pain and sciatica from Spine (2002;27:1736-1741.) concluded that
· “There is no evidence that advice to stay active is harmful for either acute LBP or sciatica.”
· “…there are potential harmful effects of prolonged bed rest...”
· “…it is reasonable to advise people with LBP and sciatica to stay active.”

In conclusion, it is important to monitor and educate those patients with acute low back pain so that they do not get lost in the medical shuffle and end up with some chronic disability.

References:
1. Deyo RA. Low back pain – a primary care challenge Spine 1996; 21:2826-2832.
2. Williams DA, Renerstein M, Durbin D., Pezzulo j. Healthcare and indemnity costs across the natural history of disability in occupational low back pain. Spine 1998; 23(21):2329-2336.
3. Occupational Low Back Pain. New York: Praeger, 1984:107
4. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation low back pain claims. Journal of Occupational Evironmental Medicine 1998, 40:261-269.
5. Rehabilitation of the Spine by Craig Liebenson second edition 2007