Back pain--whose responsibility?
Authors: M. Morrison
Journal: Journal of the Royal Society of Medicine (2002)

A symposium on back pain, organized jointly by the RSM and the British Institute of Musculoskeletal Medicine, drew an audience from many disciplines including general practice, orthopaedics, rheumatology, musculoskeletal medicine, occupational health, osteopathy, chiropractic and physiotherapy. Whose responsibility is the service? Clearly the question is topical.

The first session was directed to the present, with descriptions of current models of care, and the second to treatment in the future. Inevitably there was overlap between present and future: some of the current practices were quite avant-garde, and may become tomorrow's models of care.

Professor Gordon Waddell, co-author of the Clinical Standards Advisory Group (CSAG) report, set the scene by addressing the question ‘Whatever happened to the CSAG Report?’ Many may have judged that the CSAG's Report on Back Pain (1994), and its successors the Royal College of General Practitioners' Clinical Guidelines for the Management of Acute Low Back Pain (1996, 1999) and The Back Book (Burton et al., 1999) had had little effect on practitioners grappling with the endemic problem of back pain. But Professor Waddell showed that there has been a sea-change in attitude and opinion from the former panacea of bed-rest to the present prescription of exercise; and that the exponential rise in the cost of sickness benefits due to back pain has levelled off over the past few years—though there was some discussion regarding whether this favourable trend was due to a change in the regulations relating to entitlement to claim.

The costliness of back pain, both to the individual sufferer and to industry, was highlighted by Dr Chris Sharp, an occupational physician who has been able to demonstrate to his company's management the cost-effectiveness of a service incorporating pre-employment fitness assessment, early active intervention by physiotherapy, functional capability assessment and rehabilitation. Mr Jeremy Fairbank, consultant spinal surgeon, described the set-up in Oxford, where primary care in the community includes multidisciplinary practitioners. This is backed up by ‘secondary care in the community’ involving the use of ‘extended scope physiotherapists’—a useful method of triage that limits pressure on the spinal surgery service. A similar service has been established by the rheumatologist Dr Sarah Rae in both Exeter and Bedford, using specially trained physiotherapists; but she emphasized the need for the agreement and cooperation of general practitioners and spinal surgeons if such a service is to succeed.

An exciting and innovative project has been set up by Dr Ian Bernstein, a medically qualified osteopath working as a general practitioner (GP) in London. Originally funded by the health authority as a pilot scheme, it proved to be both clinically and cost effective. Musculoskeletal clinics in primary care provide a service to 65 GPs in 28 practices. They are designed to deal with acute musculoskeletal disorders. A flexible centralized booking point (telephone number) allows patients to have triage performed within 3 days and treatment to start within 11 days—given by physiotherapists, osteopaths or musculoskeletal physicians. The average number of treatments for each patient is 2.8, compared with 4.0 in the local hospital; and the cost is £57 per episode of care, half the cost at the local hospital.

The common belief that early treatment prevents chronicity was examined critically by Dr James Campbell, a consultant in musculoskeletal medicine in Edinburgh. Many of the statistics, he said, are clinically irrelevant because of the use of inappropriate outcome measures. In true Scottish tradition, he concluded that the case is ‘not proven’. Following him, Dr Roderic MacDonald questioned the evidence used to decry bed rest. He showed that much of this has been misquoted or misinterpreted; indeed the very papers cited against bed rest show that a few days' rest do improve the rate of recovery.

Dr Keith Bush, a musculoskeletal physician in London, outlined the indications for the use of epidurals (and selective root blocks) for those with nerve root symptoms and signs. The evidence shows that the procedure, properly performed (particularly by the caudal route), is safe; it can produce early and often long-lasting relief of pain, though occasionally repeat injections are needed.

The physiotherapist's approach was given by Dr Jennifer Klaber Moffett, reader in rehabilitation at Hull University. She cited evidence from randomized controlled trials to show the clinical effectiveness of ‘back schools’. One of the most important aspects is to help patients overcome their often ill-founded fears—particularly the fear of movement, when movement is painful. She stressed the need for a proper rehabilitation programme, involving graduated exercises together with cognitive behavioural techniques for those with chronic pain and ‘disability’. Dr Loic Burn, consultant in musculoskeletal medicine, stated that there is now good evidence for the efficacy of manipulation, particularly in the acute episode. In consequence, manipulation is now included in guidelines in New Zealand, the USA and the UK; and a knowledge of manipulation is a requirement in the training of specialist registrars in rheumatology.

The final speaker was Professor Mansel Aylward, chief medical officer and medical director of the new Department of Work and Pensions (formerly Social Security). He reminded us of the enormous scale of the problem—2.3 million people out of work on benefit, 1.5 million on incapacity benefit, costing £7 billion per annum. Of those on incapacity benefit, 33% have mental and behavioural disorders (sometimes stress related) and 21% have musculoskeletal complaints. He reminded us that 80% of those on incapacity benefit (off work for more than 26 weeks) do not work again within 5 years. Thus, his new department is stressing the need for welfare reform to enable people to remain at work or to return to work early; so there is a need for enhanced rehabilitation facilities and occupational medical services. But he warned that the Treasury needs to be convinced that any money going to such schemes is well spent. Thus, the meeting closed with his throwing down the gauntlet to practitioners in the field: ‘give us the evidence’.

No formal conclusions were reached and no resolutions were passed at this meeting; but clearly a lot has happened since the CSAG Report in 1994. People are addressing the issue in a positive manner with new approaches. Did the meeting answer the question posed? Not directly. However, there seemed to be a consensus that early treatment should be our aim—which means treatment in primary care or in the workplace. We need to provide more good evidence (with relevant outcome measures) that treatments are both clinically and cost effective. It is the responsibility of all those who deal with back pain, across the disciplines, to ensure that patients do not endure prolonged suffering of the kind that will turn them into a ‘chronic back case’.