Back pain: its management and costs to society

The aim of this Discussion Paper is to estimate the social costs of back pain in the UK and assess the potential for reducing these costs by increasing the appropriateness of management of back pain. 50% to 80% of the population suffer from back pain at some stage of their life. With or without treatment, 90% of back pain problems improve within six weeks, but repeated episodes are very common. Although back pain and its management has been the subject of several thousand research papers over the past three decades, it still remains something of an enigma. Only 15% of cases can be clearly diagnosed. However, the great majority are due to mechanical low back pain which is the focus of this paper. Due to the paucity of data it is only possible to make crude estimates of the costs of back pain to the NHS, and these probably lie between £265 million and £383 million. Most of these costs are generated in 1) General Practice, due to the large number of consultations, and 2) Hospital in-patient management, due to the high treatment cost per person. Between 1986 and 1992 sickness and invalidity benefit claims for back pain alone increased in the UK by about 104%, while claims for other causes of sickness increased by 60%. The intangible costs of back pain and disability affecting the individual are likely to be considerable. When the problem has become chronic and intractable after about six months, the individual’s function and social activities may become severely curtailed. The General Practitioner is the key worker for back pain patients, and recent data suggests that these account for between 5.8 to 8.6 million consultations every year. Most consultations are associated with a prescription for medication, and advice to rest, despite the fact that the evidence is heavily weighted towards early resumption of normal activities. The processes are not well understood and treatment therefore is usually palliative. High quality outcome research is hampered by a number of problems, such as diagnostic ambiguity, and the powerful effect of a placebo in reducing pain. There is some evidence of the usefulness of spinal manipulation, exercise and patient education to reduce back pain disability, although more research is needed to clarify which particular interventions are most effective for which category of problem. In the UK, the use of 900,000 hospital bed days each year for back pain patients requires careful review. Hospitalisation is not only expensive, but also in combination with prolonged bed rest and excessive investigations may be harmful, unless surgery is clearly indicated. Risk factors for back pain include manual handling, static postures, vibration exposure and smoking. Both physical and psychosocial factors in the workplace have been linked with back pain. A number of intervention studies have indicated that both primary and secondary prevention of back pain and injuries in the workplace can be cost effective, but this work is incomplete. Once the back pain has become chronic, more aggressive rehabilitation programmes appear to be the most effective way of returning individuals to their previous occupation. The goal is to reduce the disability that may result from mechanical lower back pain by appropriate active management. Reviews of the literature have pointed to more effective approaches to managing the problem of common low back pain, but these now need to be translated into practice to ensure that resources are used effectively.