Healthcare

Imagine you’ve been dealing with debilitating back pain for a few weeks. You finally give in to the nagging from your family/partner/friend telling you that you should see a doctor. The appointment is short, and you’re told to rest and take Tylenol. You leave the appointment frustrated and feeling dismissed. Like me, I’m sure you know someone who, or you yourself, has left their doctor’s office feeling this way.

Let me be clear, not all doctors are like this. Many well-intentioned physicians go the extra mile for their patients and take the time to listen to their concerns and circumstances. So let’s flip the previous hypothetical on its head. You’ve been dealing with back pain for weeks and have finally decided to see your doctor (mostly because your family couldn’t take your complaining anymore). You sit down with your doctor and they’re engaged in the conversation, asking lots of questions about your pain and experience, and wow, they’re even ordering you an MRI! You leave feeling validated that someone took you seriously and is advancing you to further stages of investigation. Problem solved, right?

Not quite. The rest of this newsletter will break down a few areas where the typical primary care pathways may fall short for individuals with back pain.

Side note, if you live in Canada like me, the average wait time for an MRI is around 4 months [1]. The wait time varies based on the perceived urgency and severity of your health concern. So your wait could be much longer. What are you supposed to do in the meantime? You have this pain, no one knows what’s causing it, and you have no practical instructions other than try to rest, for now.

Rest

Physician recommendations vary widely between doctors and healthcare systems. In Australia, ~25% of general practitioners believed that their back pain patients shouldn’t return to work until their pain was almost entirely gone [2]. The situation is much more dire in low or middle-income countries, with the same study reporting that 67% of patients were treated with bed rest in Qatar and 63% in India believing that bed rest is an important part of therapy. Further, 90% of rheumatologists in Brazil and 46% of Indian physiotherapists advised rest [2].

Rest sounds perfectly logical, but the reality is that people have jobs, kids, and responsibilities that NEED to be tended to. Further, back pain is aggravated by many normal activities of daily living, not just obvious things like vigorous exercise or manual labour. It’s difficult to truly ‘rest’ in a way that alleviates back pain. In fact, guidelines support staying active and keeping moving, not resting. A review of ‘bed rest’ vs ‘stay active’ advice found that staying active led to slightly better pain outcomes [3]. Individuals who don’t or can’t return to work following an episode of back pain tend to report greater physical ailments and higher rates of anxiety and depression [4].

So what is the evidence suggesting? After hurting your back, it may be beneficial for your mental and physical health to continue participating in activities of daily living and work, where possible, in ways that don’t spike your pain. I would think of it like this: find ways to move without severe pain and continue moving that way. Reduce the intensity and occurrence of things that really cause you pain, but keep moving forward.

Mental Health/Depression

It was briefly mentioned in the last section, but mental health, particularly depression, is an important factor in back pain prognosis.

In a study that looked at individuals with a history of low back pain, baseline depression and low physical health were at higher risk for future troublesome back pain [5]. Depression was the strongest predictor of negative return to work outcomes in a review of all musculoskeletal disorders (over half were neck and back pain related) [4].

A systematic review looked at the relationship between depression and new episodes of low back pain. They found that a person with depression had 59% (odds ratio 1.59) higher odds of future low back pain episodes compared to a person without depression [6].

Image from: Pinheiro et al., (2015)

These are not small claims. They assert that our expectations, attitudes, and outlooks impact back pain prognosis. This doesn’t mean that pain is all in our heads. It means that our beliefs and attitudes about our pain can impact our recovery. It’s for this reason that I’m including it as an area where our healthcare system may fall short. If they aren’t already, our primary care physicians need to be aware of the impact that depression (and beliefs about recovery/pain) can have on back pain recovery. Back Again Assessments includes the Back-PAQ – Back Pain Attitudes Questionnaire as part of the screening process to identify helpful vs unhelpful beliefs towards back pain.

Ambiguity of Diagnosis and Imaging

This newsletter has ‘challenges and problems’ in the title for a reason, and diagnostic imaging is no exception. In my opening hypothetical example, I mentioned a scenario where someone was referred to get an MRI. Imaging is recommended when so-called ‘red flag’ symptoms are present. Red flags include: bowel or bladder dysfunction, severe neurological deficits, saddle anaesthesia/perineal sensory changes (change in sensation to the areas that would contact a saddle while sitting on one), fracture risk, or infection concerns (and others). Surely, an MRI referral (or other imaging like x-ray for fractures) only occurs if clinicians see red flags, can’t pinpoint a pain source, and have had no success with conservative treatment…right?

Unfortunately no. There’s widespread use of imaging across the world in scenarios where there is no indication of serious pathology, and sometimes no attempt at conservative treatment. In Norway, 38.9% of people presenting with back pain to a general practitioner were referred for imaging. In the US, 53.7% of people referred for imaging did not have any red flag symptoms, and the list goes on [2].

So why is this a problem? Well, there are the obvious 4-month wait times for MRI appointments that occur in some countries due to extremely liberal use of imaging as a diagnostic tool. It gets far more complicated. One study found that 34% of the herniations identified by MRI were asymptomatic [7]. While this is not true for every spinal condition, it is common for individuals to be referred for imaging while in pain and find nothing on the scans. This calls into question the association between abnormalities found on imaging and pain. That is to say, there are people, when sampled at random, that had abnormalities in their spines (bulging disc, minor herniation etc) and no pain or symptoms. Conversely, some people had back pain, and imaging did not find any structural abnormalities. Frustrating, I know.

The ambiguity surrounding back pain diagnosis is an issue for people seeking health insurance or benefits coverage. Insurance companies want proof of a diagnosis.

Safety note (not medical advice):
If you notice new bowel or bladder problems, saddle/perineal numbness, rapidly worsening leg weakness, unexplained fever, night sweats, or a recent serious fall/trauma with back pain, it’s important to seek medical care.

So where does that leave us?

If someone does not have any red flag symptoms and they’re in pain, there’s a framework that can help: identify pain triggers/provokers, reduce exposures when possible, and build a more resilient back. Reasonable goals include restoring function, building confidence, and getting back to daily life. If this approach sounds interesting, please consider one of our assessment reports to help you through the process.

References

1. Fraser Institute: https://www.fraserinstitute.org/commentary/canadians-continue-experience-long-waits-mris-and-ct-scans
2. Foster et al., 2018: https://pubmed.ncbi.nlm.nih.gov/29573872/
3. Hagen et al., 2010 https://pubmed.ncbi.nlm.nih.gov/20556780/
4. Cancelliere et al., 2016: https://pubmed.ncbi.nlm.nih.gov/27610218/
5. Nolet et al., 2016: https://pubmed.ncbi.nlm.nih.gov/26208942/
6. Pinheiro et al., 2015: https://pubmed.ncbi.nlm.nih.gov/25989342/
7. Hartvigsen et al., 2018: https://pubmed.ncbi.nlm.nih.gov/29573870/