PETE MOOREwas when he Woke up one autumn morning with back pain so excruciating that he struggled to dress himself. His doctor in Romford, an English town, referred him to hospital for anMRIscan; this showed that some of the spongelike discs that separate the spine’s vertebrae were bulging out of the slots into which they customarily fit. Such “slipped” discs can be caused by an injury; but they are also the sort of thing which can just happen with increasing age.
Mr Moore received a prescription for opioids to help him cope with the pain; but the pain persisted, and he found himself becoming loopy. Unable to work or do much else, Mr Moore, who had been a painter, sank into depression. Three years into his ordeal, he says, he was “thinking of ending it all”.
There are also a lot of treatments for the back itself. Spines are injected with cement-like mixtures or fitted with various types of medical hardware. Vertebrae are fused together, discs excised or tampered with in various ways. Yet — unsurprisingly, if it is largely the pain mechanism which is the problem — there is a growing body of evidence that the benefits all this offers to most patients are limited or non-existent.
Even just looking at the back causes problems. Only 1-5% of people with back pain have a problem that requires urgent treatment, such as an infection or a tumor; in such cases the pain will tend to be accompanied by other symptoms too, such as weight loss, fever or incontinence. In America and western Europe guidelines say that it is only when such red flags are present that a patient presenting with back pain should promptly be given an x-ray or anMRIscan. Yet general practitioners and hospitals routinely ignore this, sending – 84% of people with back pain to be scanned — far more than they did 20 years ago. According to Jan Hartvigsen of the University of Southern Denmark there is a broad consensus that about (****************************************************% of such scans are useless.
That might be fine if the scans were sometimes helpful and never harmful. But few bodies are completely normal, and learning of your particular “abnormalities” in a medical setting and while suffering is alarming even if a healthy back might look just as odd. Disc “degeneration” is seen in roughly half of young and middle-aged adults with back pain, but also in a third of those with no pain at all. Some 60% of people with back pain have disc protrusion, a form of “slipped” disc; but so do nearly 40% of people who are pain-free.
Both patients and doctors, though, tend to think that if they can see something they should do something. Some sufferers catastrophise the news into the idea that they have a broken, fragile back and start avoiding normal physical activity — not least, says Ms Knight of St Thomas’, because doctors often fail to explain to them that abnormalities are, in fact, quite normal, and that degeneration can basically be wear and tear. The stiffness and weakening of the muscles this inactivity brings often makes things worse. And doctors may take abnormalities as a cue for further medical attention. Many studies have confirmed that patients who receive unwarranted imaging in the first few weeks of back pain are more likely to have surgery and unnecessary follow-up tests than similar patients spared the scans — but that they enjoy no benefits in terms of pain reduction or lessened disability.
In 2013 Cigna, an American insurance company, ran a follow-up study on patients who had undergone procedures in which vertebrae are stitched together with implanted bolts and braces. “Spinal fusion” of this type is a frequently used surgical response to back pain that is associated with the degeneration of spinal discs; in 2017 there were roughly , 15 such surgeries in America. The company found that two years after treatment 87% of customers were still in severe severe enough for medication or some other treatment; (****************************************************************% had more surgery.
This is going to hurt
It all sounds depressing. It need not be so. There are ways of dealing with back pain that waste much less money and leave patients less distressed and with a greater sense of their own agency.
Mr Moore, the patient with whom this story began, tried to come to terms with his disabling pain by starting a support group for fellow sufferers. A psychologist from St Thomas ’, which has the biggest pain clinic in Europe, came to talk to them about“ graded exercise ”and the importance of pacing themselves when going out and about. “Nobody had told me I could do these things,” says Mr Moore. In (**********************************, three years after back pain had come to dominate his existence, a two-week residential program at the pain clinic taught him what it teaches people today: exercise daily; accept flare-ups as temporary setbacks; Don’t get fixated on the pain. Learning to keep going this way “saved my life”, Mr Moore says.
The program, explains Ms Knight, aims not to reduce pain so much as to add to life. People naturally struggle against the pain, which means they are burdened with the pain and the struggle too. “If you can drop the struggle,” says Ms Knight, “then you have your hands free to do more.” Patients are taught how to gradually overcome their fears of exercise and daily activities that can cause some pain. The goals that they start with can be as simple as calling a friend and meeting for a coffee, or attending a wedding. In a typical class of ten people, Ms Knight says, one or two decide that the approach is not what they want, and may drop out. Most of them take away at least some skills which add to their quality of life. One or two, like Mr Moore, find the program life-changing.
Various countries have tried to encourage people with back pain to stay active, with promising effects. One such campaign, in Australia, is reckoned to have led to a (*******************************************************************% reduction in the number of doctor visits for back pain and a 20% decrease in related medical costs. Such campaigns appear to work best when they provide practical advice on how to stay active and at work despite the pain, and when as well as speaking to the afflicted they enroll employers, clinicians and unions as partners.
Activity is not a panacea, and if leading an active life with pain is better than withdrawing from the world, it is still not ideal. But interventions like this seem to offer people more succour than highly medicalized approaches. Unfortunately, medical schools, patient expectations and the policies of insurers and governments all sustain the latter.
All around the world, family doctors are woefully undertrained to treat common, unglamorous conditions such as bad backs. In most medical curricula musculoskeletal conditions, like back pain, are a minor feature. Back pain is “not sexy” for medical students, says Chris Maher of the University of Sydney. Even if they are going to be family doctors they still want to hear about cures for cancer and impressive forms of surgery, rather than humdrum stuff like back pain or preventing falls in older people.
Spinal surgeons, for their part, often take a dim view of evidence that what they do may be ineffective. Surgical training is based on an apprenticeship model. “You learn from a master, a great guru, and you do what they taught you. You don’t learn from a paper in theBritish Medical Journal, ” says Andrew Carr, who heads the department of orthopedic surgery at Oxford University. Surgeons generally consider an successful operation if the incision is small, things heal nicely and there are no complications, says Maurits van Tulder from Vrije University in Amsterdam. If they ever hear back from patients, that is usually from those for whom the operation worked — which leads surgeons to believe that it works most of the time.
Though research on surgical results is becoming a lot more widespread, it is still hard to convince surgeons that what they have been doing for most of their careers is ineffective, says Dr Carr. It is also hard to convince patients that, when it comes to treatment, less may be more. Told that the best thing they can do about back pain is exercise their body and their patience, they often think they are being fobbed off; a deluge of online marketing for ineffective treatments does not help. Some harangue their doctors for scans or injections, or find a new more biddable one. For a busy doctor, says Rachelle Buchbinder of Monash University in Australia, “it’s easier to prescribe an x-ray than explain why you don’t need one.”
Once pain becomes Chronic, persuading sufferers that the cause is not a fixable physical defect becomes much harder. Graeme Wilkes, a British doctor, says that he might spend an hour telling a patient that the things seen on hisMRImay not be the reasons for his back pain, and that a spinal injection is unlikely to help. “The reason they’ve got back pain is that they have financial problems, marital problems, disabled children, they are not sleeping at night — not those changes in theirMRIscan, ”says Dr Wilkes. “And they go home and someone says’ Oh, that’s absolute rubbish that you can’t get an injection, because my mate at work had it and he was much better afterwards. Don’t listen to them, go back to yourGPand get referred ‘. ”
But the biggest reason why so many people with back pain get the wrong treatments is that governments and insurance plans pay for them. In America, Australia and the Netherlands health plans pay for back operations that cost $ 43, 01 – 183, 002 apiece. American plans often support the alternative therapy offered by chiropractors. There is some evidence that this may do some good in back pain, but the research is patchy and any benefits small and short-lived. Yet the same plans typically offer little support for physiotherapy to the same end. If a therapy has been accepted by an insurance company, or a government scheme like America’s Medicare, it is very hard to get it removed, even if evidence for effectiveness persistently fails to turn up. “Once they are in, it is hard to take them out,” says Dan Cherkin from the Kaiser Permanente Washington Health Research Institute. The manufacturers of medical devices are very good at lobbying to get them covered as treatments. They are also “incredibly effective” in marketing their wares to doctors, says Richard Deyo of Oregon Health and Science University.
Back pain is big business for many surgeons, doctors and chiropractors. “If we stop doing low-value care, some entire professions have to change fundamentally what they do,” says Lorimer Moseley of the University of South Australia after enumerating a long list of ineffective treatments. In some systems cupidity encourages such things. In America, where procedures are more lucrative than talking to patients, an unscrupulous doctor might prefer to spend a – minute appointment giving a patient an injection rather than some education, just as a harried one might.
Other countries have had some success with an approach called “Choosing Wisely”, in which doctors explain to patients the evidence on the effectiveness of various treatment options and decide together what is best given each patient’s personal goals (which could range from simply wanting to be able to play with their grandchildren to cycling or running). In Britain there has been a determined move towards triage which assigns back-pain patients to more or less intensive treatment depending on the complexity of their problems. In Australia some emergency rooms have started sending some back-pain patients brought in by ambulance straight to physiotherapists, which avoids a significant amount of hospitalization.
But when professional associations in America urged doctors to take up the Choosing Wisely model their campaign made almost no difference to back-pain treatment — perhaps because doctors were under no obligation to change, says Dr Deyo. Nor has a change in the advice provided by the American College of Physicians had any great effect as yet. In 2019 the college stopped recommending medication as an initial response to back pain, suggesting instead acupuncture, yoga, tai-chi and psychological therapies aimed at reducing stress, all of which have been shown to reduce pain-related disability. Insurers have taken note, with some now covering some or more of these alternatives. That will make it easier for doctors moved to change their practice to do so.
Another approach might be to nudge doctors incrementally, rather than to change their practices once and for all. Tweaking the interface of the electronic systems doctors use to orderMRIs so that it takes them longer to place an order has been shown to reduce the number of unnecessary scans. Adding a pop-up reminder explaining why imaging is frequently unnecessary has also shown effects.