In late 2012, an outbreak of fungal meningitis in the US was traced to contaminated epidural steroid injections administered for back pain. By March this year, more than 700 people were being treated for persistent fungal infections and 48 people had died.
A bad result by any measure. But to make things worse, says Professor Chris Maher, even the uncontaminated injections were unlikely to have offered much pain relief for the patients. "In the short term the injections are only marginally more effective than a placebo and in the long-term, no better than a placebo."
Maher, the director of the Musculoskeletal Division at the George Institute for Global Health, says there are many pointless things that people do to deal with bad backs, egged on by website promises of cures or well-meaning but ill-informed clinicians. Epidural injections are just one of these.
"We've got a pretty good idea about what works for back pain, but unfortunately people tend to get the wrong care. In fact, over time, the treatment being provided has got worse," he says.
Most people with acute back pain, about 90 per cent, have non-specific back pain, Professor Maher says.
"Clinical guidelines say don't send these people off for imaging, encourage them to remain as active as possible and use simple pain killers as a starting point," he says. "Instead, what tends to happen is they get sent off for imaging straight away, they get prescribed much more complex pain medicine than they need and they often get told to go to bed."
These people don't need a formal exercise program, Maher says, but they do need to get active again. "The treatment that's endorsed for acute back pain is quite simple, but patients get more complex care; they get more of the wrong sort of treatment," he says. And this approach has ongoing effects.
"If you send people off for imaging they are more likely to end up being offered surgery," Maher says. "If you send them off for imaging, about a third will come back with something found." Patients then focused on the imaging results and could become quite disabled by them.
"If the primary-care clinician doesn't explain it correctly, they'll think there is something seriously wrong with their back," Maher says. "There's also a downside with prescribing stronger pain medications, such as opioids. In the US over the past decade we have seen a major increase in prescription of opioid analgesics; and at the same time the number of deaths involving opioid analgesics has quadrupled."
Maher doesn't underestimate the pain caused by bad backs, but it is a condition that shouldn't kill you, which is worth keeping in mind when considering the risk and benefits of a treatment you may be offered.
In a survey of the care provided to patients presenting with new episodes of lower back pain, Maher and colleagues looked at more than 3500 patient visits before and after the release of clinical practice guidelines. The results showed little difference in the "before" and "after" stats. The investigators concluded: "The usual care provided by clinicians for lower back pain does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. The unendorsed care may contribute to the high costs of managing [the pain], and some aspects of the care provided carry a higher risk of adverse effects."
In relation to medication, where a simple analgesic such as paracetamol is considered the best first option, the most common medications recommended or prescribed were non-steroidal anti-inflammatories (37 per cent), followed by opioids (20 per cent), with paracetamol coming in last (18 per cent). Fewer than one in five patients received paracetamol. Worse still, less than one third of those received the recommended dose.
The report says that while the guidelines caution against the routine use of imaging, this procedure was nevertheless requested for a quarter of the patients presenting with new lower back pain. Simple radiographs have stayed at much the same rate, but CTs and MRIs have become more popular. And only about one-fifth of patients were provided with advice, education and reassurance of a favourable prognosis as suggested by best-practice guidelines.
Having identified a problem, Maher has been working with the National Prescribing Service to develop solutions. The first step was an electronic decision support tool for clinicians, Back Pain Choices, that provides guidance on the management of back pain in primary care. A patient option is also planned.
What magnifies the significance of this bad treatment is that so many people suffer with bad backs. "At any point in time, 25-30 per cent of the population will have back pain and up to 80 per cent of people will have back pain at some time in their life," Maher says.
"While we used to dismiss complaints about bad backs, the recent 2010 Global Burden of Disease claims it is the most disabling health condition in Australia, and that would be the same across the world."
That study showed in terms of years lived with a disability, lower back pain was ranked number one, with other musculoskeletal disorders ranked third and neck pain fourth - this in a group of diseases and disorders that included depression, anxiety, diabetes, chronic obstructive pulmonary disease and osteoarthritis.
What triggers back pain is not clear, though there now seems to be a strong genetic component. When researchers have looked at possible risk factors such as vibration, smoking, lifting or being overweight, the findings have been inconsistent. Anything coming out as positive has only had small predictive effects. Maher believes this is because the research hasn't controlled for genetics.
And not knowing the risk factors makes it impossible to give any useful advice on how to avoid back pain. Maher points to an example of where public policy has jumped the gun on research and failed. He is referring to occupational health and safety training on the safe way to lift.
"A study nearly two decades ago in the US postal service looked at this and found it was totally ineffective," he says. "People went around to the workplace, taught postal workers how to lift correctly and improve their posture. There was no change in the incidence of back pain between the control OH&S group and the group that got the intervention. The only things that has been shown to work is giving people an exercise routine after the occurrence of back pain.
"We are doing a study at the moment to try and see what does predispose people to back pain, but it's probably the first that's ever been conducted properly."
Yet Maher says five to 10 more years of research is needed before researchers will be close to knowing how to prevent back pain.
Of those who report a recent onset of back pain, half will have a recurrence of that pain within a year. It's unusual to have back pain only once in your life. Maher says that perhaps we need to see it as a chronic condition. "It's almost like the common cold. Maybe we just have to accept people will get it and learn to manage it better."
For a start, he'd like to see public health messages to combat misinformation. "The prevalence of back pain hasn't changed, but unhelpful ideas about it have increased. Ideas such as: if you've got back pain, you've damaged your back; if your back hurts, don't move; and if you've got back pain, a disc is out of place.
"There are lots of health campaigns about weight loss and cardio-vascular disease, but you don't see many health messages about back pain."
- Sydney Morning Herald
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