Chronic lower back pain (CBP) is increasingly common in the Western world. With the commonality of the back pain comes an abundance of pain relief options - so many that it can be confusing and difficult for patients to be properly informed of the options, making it virtually impossible to make informed decisions. The issue reaches beyond the patient to the treating physicians and the third-party payers as they all try to find the best and most economical way of treating their patients.
Unlike other areas in medicine, such as cardiology or neurology, treatment options for chronic LBP do not always have the extensive clinical research to back up claims of effectiveness.
The authors of this article have compared the myriad of available treatment and management options to a supermarket with all its offerings. The authors write that this is a good comparison, considering that it often seems as if they are shopping when attending commercial displays at spine meetings, along with their promotional material.
The market for LBP management treatments is large; it is estimated that 85 percent of people will experience LBP at some time in their life. The cost of LBP is high, both directly and indirectly. People with LBP often cannot work (indirect cost) and their treatments can be costly (direct cost). The authors refer to a review that states direct costs of LBP, in the US, are estimated to be at 12.2 billion to 90.6 billion dollars annually - about 45 to 335 dollars per person per year.
The treatments, as the authors explain, can be divided into 10 different supermarket aisles, with each aisle chock full of therapies. Aisle 1, for example, contains pharmacological treatments, including nonsteroidal anti-inflammatories (NSAIDs), muscle relaxants, and other types of medications to manage pain. Aisle 2 contains the manual treatments, such as manipulation and massage. Other aisles contain surgical options, lifestyle therapies, and even alternative or complementary treatments.
An important issue that comes to light is the difficulty in choosing between the different options. Seeing as there are over 200 different options, it is not a simple thing for a clinician to keep track of them all - keeping in mind that new treatments become available regularly. Not only must the physicians be aware of the different options, they must be aware of all aspects of the treatments, including the relative harms and benefits for each individual patient.
Often, when patients develop chronic LBP, they try to treat themselves first or they do research to see what treatments might be best for them. To do this, they have to choose which healthcare professional would best manage their care. According to the authors, this means deciding between many different groups of professionals: anesthesiologists, occupational medicine specialists, orthopedic surgeons, neurosurgeons, neurologists, pain management specialists, osteopathic physicians, physical medicine and rehabilitation specialists, internists, and family physicians (doctors); massage therapists, occupational therapists, pharmacists, physiotherapists, psychologists and sport trainers (allied health); and acupuncturist, chiropractors, faith healers, homeopaths, napropaths, and naturopaths (alternative medicine practitioners). However, just knowing the available practitioners may not be any help if the patients don't understand the educational and professional background behind each group. Usually, they must take the professionals' word of experience at face value.
Now, taking all the different types of healthcare providers who may be able to treat chronic LBP and throw in that each one within the groups may - and do - have a different approach to treatment. The example in the article refers to how one surgeon may favor one surgical approach to another, while another surgeon may only use the other approach. Different analgesics in different combinations may be prescribed, alone or with manual treatments, or other types of specialties.
Looking at just the amount and combinations of treatments available is overwhelming, but then there is the aspect of what the authors call "branding." Some practitioners feel that their way is the best and only way to treat chronic LBP and they may belittle or thwart any attempts of the patients who may want to seek alternate therapies. Instead of working with each other, the practitioners work against each other. This is best evidenced by how many doctors feel about chiropractics or some alternative medicines. This causes patients to be confused or maybe even deceitful in a way, because they may seek other types of help but not want to mention this to their primary caregivers.
Another concern is the commercialization of treatment for LBP. The authors use the example of patients who look for information on the Internet and are directed to commercially sponsored sites or discussion groups. This type of activity may keep patients away from sites that may offer more objective and effective interventions.
The authors conclude that articles reviewing treatment for chronic LBP should follow a specific format for professionals to be able to assess the treatment's efficacy and viability. The articles "should clearly define and describe a particular intervention, explain the theory or scientific evidence regarding efficacy, discuss potential or known harms, and summarize this evidence for nonexperts."
Scott Haldeman, DC, MD, PhD, FRCP(C) and Simon Dagenais, DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. In The Spine Journal. February 2008. Vol. 8. Issue 1. Pp. 1-7.
