Low back and neck pain is an increasingly widespread and expensive condition worldwide, costing the US alone $88bn a year – the third highest bill for any health condition.
Millions of people worldwide suffer from low back and neck pain, most of it unexplained, although some professionals think it may be worsened by sitting at desks all day, carrying bags and general bad posture. Episodes of acute pain are very common, but experts say that medical investigations only make things worse and the best cure is often to take painkillers, exercise gently and wait for the pain to pass.
The rising bill for treatment in the US has been uncovered in a new study by the Institute of Health Metrics and Evaluation (IHME) at the University of Washington, which looked at public and private spending on all diseases in 2013. Diabetes was in first place on $101.4bn and heart disease was second with $88.1bn. But neck and lower back pain treatment costs were close behind, at $87.6bn. The team split cancer into 29 separate conditions, which meant that none of them made the top 20, although combined the costs of treatment came to $115bn.
The most remarkable thing, said Joseph Dieleman, lead author of the paper published in the Journal of the American Medical Association, was the increase in treatment costs for lower back and neck pain, running at 6.5% a year against 3.5% overall. “In absolute terms, there was an increase from $30bn in 1996 to $88bn in 2013,” he told the Guardian.
The numbers of people suffering low back and neck pain in the US had not changed much, he said, but the spending had soared. Three things were driving the rise, said Dielman: individuals with pain going more often to outpatients’ clinics, increases in the costs and quantity of treatments given to people admitted to hospital, and a larger older population.
Surprised by what they found, Dieleman and his colleagues now plan to do similar work looking at the costs of treatment of low back and neck pain and other diseases in England, Norway and Switzerland.
What they already know is that low back and neck pain is a huge worldwide problem. The latest Global Burden of Disease (GBD) study, also produced by the IHME and published by the Lancet, showed it was “the leading global cause of disability in 2015 in most countries”. In the UK, a third of all long-term sickness absence from work, and nearly a fifth of any sick leave, is caused by musculoskeletal disorders, which is mostly lower back and neck pain, according to the Work Foundation.
“It’s about 30% of GP consultations,” said Karen Steadman, health, wellbeing and work lead at the foundation. A lot of patients have other health complaints at the same time – so-called co-morbidities. “About a third have co-morbid depression,” she said.
Dr Andrea Furlan, a co-ordinating editor of Cochrane Back and Neck – one of the collaborating groups of scientists who assess the worldwide evidence for which treatments work – said back or neck pain affect maybe eight out of 10 people at some point. “Almost everybody in the world will have some kind of back pain in their life,” she said.
Acute lower back or neck pain, which can last for a few days up to a couple of months, can be extremely debilitating, she said. Furlan knows this, as quite apart from being based at the Institute for Work and Health in Toronto, Canada, she has experienced it herself. “It was so painful I had to lie on the floor,” she said. “I was sure I had ruptured a disc or ligament.”
But she also knew she should not get it investigated. “The first thing you have to remember is don’t x-ray, don’t MRI and don’t CT scan – no investigation. I was desperate to have one.
“Thank goodness I didn’t (get it investigated) because that’s where things go wrong. I’m 47 years old. When you do an investigation, there is a chance you are going to find something wrong in the spine. Then somebody will want to intervene.”
Injections, electrical nerve stimulation, opioid drugs and a whole host of other interventions are not recommended for lower back and neck pain. The Cochrane group have found no evidence in favour of using these or many other interventions; in the UK, guidance from the National Institute for Health and Care Excellence advises healthcare staff not to offer them.
There are people who will be “red flagged” for investigation because of their age, a fever or other issues, but most people will be advised to keep working, keep moving, keep exercising and taking painkillers and wait to get better. “Rest for acute back pain is the worst thing you can do,” said Furlan. After three weeks, her own pain was gone.
It is important to try to prevent acute pain from becoming chronic pain – the sort that does not permanently go away. Treatment can make things worse, but there is also a mental health element to much chronic pain. Those at risk of developing chronic pain are “yellow flagged”, said Furlan, and risk factors include depression and a lack of social or workplace support. Those with chronic pain will need interventions, which may include professional physiotherapy but also relaxation exercises, meditation and mindfulness.
The epidemic of lower back and neck pain is not surprising, said Furlan. “The spine is a part of the body that is so fragile. People have no idea,” she said. “It is unbelievable what the spine does.” It is also supporting increased weight and changed posture in the many people who have become obese in recent years – plus carrying heavy bags around and tension in neck muscles as people work at computers does not help.
Ending the epidemic, however, is going to be hard.