Bed Rest Not the Best for Back Pain, and other new findings

Low back pain affects 540 million people worldwide and is the leading cause of disability, but vast numbers of people with lower back pain across the world are being harmed, not helped, by the surgery, injections and dangerous opioid drugs they are given, according to a major new report.

Investigating using MRI scans is counterproductive, the experts say. MRIs will pick up physical abnormalities that may not be the source of the pain.

Their review of evidence from around the world suggests low back pain should be managed in primary care what these people really need to get better is exercise and the earliest possible return to work and their normal life, experts say.

But inappropriate tests and treatments are common. Many patients are treated in emergency rooms, told to take time off from work and rest, referred for scans or surgery, and prescribed painkillers that include addictive opioids, the researchers said.

In some countries, treating unexplained back pain is a lucrative business for doctors and hospitals, and the three papers in the Lancet medical journal, released on Wednesday, call on governments and health leaders to act together to “tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo”.

In the United States, low back pain leads to 2.6 million emergency room visits each year. A 2009 study reported that opioids were prescribed in about 60 percent of such cases. Only about half of Americans with chronic back pain are prescribed exercise, the series reported. Worldwide, disability from chronic back pain has risen more than 50 percent since 1990, and the trend is expected to continue as the number of seniors grows.

In many countries, painkillers that have limited positive effect are routinely prescribed for low back pain, with very little emphasis on interventions that are evidence based such as exercises according to the study.

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Evidence shows that fusing the discs in the spine, inserting artificial discs or giving spinal injections does not usually help. Nor does bed rest and staying off work.

Low back pain mostly affects working-age adults and a specific cause is rarely pinpointed. Though most cases are short-lived, about a third of patients have a repeat episode of low back pain within a year. The researchers said it is increasingly viewed as a long-lasting condition.

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Investigating using MRI scans is counterproductive, the experts say. MRIs will pick up physical abnormalities that may not be the source of the pain. Scans often result in surgery or other interventions, but the evidence shows that fusing the discs in the spine, inserting artificial discs or giving spinal injections does not usually help. Nor does bed rest and staying off work.

There is also concern about the rising number of opioid painkiller prescriptions in the NHS. Recent trials have shown they are not more effective than other much safer drugs, yet many patients are still being put on drugs that have opioids in them. People should be given “the safest possible drugs for the shortest possible time at the lowest possible dose, according to doctors interviewed.

Prescriptions for back pain in the USA have fuelled the opioid crisis there. The epidemic of addiction and rising mortality resulting from increased opioid prescribing in the USA over the past 20 years is a dramatic example of the disastrous effects of damaging medical intervention, write the Lancet series authors.

The experts call for health professionals and patients to adopt what they call a “positive health” approach, defined as “the ability to adapt and to self-manage, in the face of social, physical, and emotional challenges”.

That involves changing beliefs about back pain, so that doctors help patients to live “meaningful, high-quality lives” while people become less likely to expect a diagnosis or a cure.

It’s clear from this study that much more needs to be done worldwide, to dispel myths around the best ways to treat back pain – rest, for example, is one of the worst approaches, yet this advice is commonplace in many countries.