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Back Pain — The Growing Epidemic
February 1995 Volume 81. No 2
ISSN 0031 9406
Journal of The Chartered Society of Physiotherapy 14 Bedford Row, London WClR 4ED Telephone 071-242 1941 Fax 071-831 4509
BACK PAIN
- THE GROWING EPIDEMIC
Back pain has been a problem to mankind for as long as there are documented records. During the last decade it has reached epidemic proportions in the industrialised nations, resulting in escalating costa to the community. A comparison of Sickness and Invalidity Benefit for back incapacity (in Great Britain) between 1978/79 and 1991/92 indicates an increase of 208.5% whereas for all other musculoskeletal incapacities the increase is 136.4%.Circulatory diseases have increased by 9196, and mental disordersby 8496, while respiratory dieeaseshave decreased by 24.8%. During this time there have been various changes in the benefit regulations but these figures clearly illustrate the increasing prevalence of back pain. This and other aspects of the problem led the UK Health Ministers in 1992 to set up a Clinical Standards Advisory Group (CSAG) with the remit ‘to advise on standards of clinical care for, and access to and availability of services to NHS patients with back pain’. The committee decided to focus on acute low back pain (LBP) and set out to study epidemiology, the development of management guidelines, and the current NHS services, and to make recommendations on the future organisation of NHS services for patients with back pain. The CSAG report* was published in December 1994.In the report the value of physiotherapy is acknowledged both for the treatment of patients and for specialist secondary opinion. It is recommended that direct access to physiotherapy for GPs should be universally available, thus reducing the wastage of resources incurred when patients are inappropriately placed on waiting lists to see rheumatology or orthopaedic consultants in hospitals. The group recognises that effective implementation of the recommendations will lead to an increase in demand for physiotherapy services. This however should be made possible by redistribution of resources between primary and secondary care, rather than by any increase in funding.
Studies undertaken on behalf of the CSAG indicated that the annual cost of NHS services for back pain was approximately f 480 million in 1993; ca&a in lost production wem very approximately f3.8 billion and in DSS benefits f 1.4 billion. It seem possible thedore that there is a substantial impact to be made on the economic well being of the country as well as the reduction in misery and human suf€ering by accessible, high quality treatment from chartered physiotherapists. The CSAG representatives visited eight Health Districts and some of the findings were: .The NHS reforms were in general stimulating new and improved services for LBP (a point particularly welcomed by the Government!) OBest rest is not the answer. OTime spent on assessment reaps dividends. OPatients should be educated to be responsible for managing their own problem. OMore emphasis is needed on prevention. O G P referral to a physical therapist (physiotherapist, osteopath, chiropractor) will benefit patienta OAsian communitiee may be reluctant to be examined for LBI? OGW find it difficult to know which patients to refer to which therapist. O G P direct a c c w to physiotherapy in hospital or clinic can be achieved with short waiting times. .There is an emerging acceptance of the role of the practitioner physiotherapist in GP practices. O A second-opinion service for GPe could be physiotherapist led. OPhysiotherapiate, oeteopaths and chiropractors should collaborate in every District.
The report includes management guidelines which have been produced in collaboration with a panel in the US and are similar to Swedish guidelines. A careful history and examination is eesential and a diagnostic system is suggested to form the basis for decisions about management. The triage is simple backache, nerve root pain and possible serious spinal pathology. Diagnostic indicators are given for each, and should identify the small number of patients requiring urgent and emergency referral to a hospital specialist. An increased role and remurces are recommended for physical therapy for back pain, provided that resources are used to provide interventions of proven value. This constitutes an important challenge to chartered physiotherapists. In the report the term ‘physical therapy’ is used to denote osteopaths and chiropractors as well as physiotherapists and the recommendation is that
NHS patients may be treated by any one of the three professions subject to satisfactory audit. The interventions identified as being of ‘proven value’ are: 0 Manipulation 0 Active exercise and rehabilitation 0 Patient education and self-management 0 Prophylaxis. The report states that manipulation is seen as an effective method of providing symptomatic relief and should be available as a therapeutic option for the treatment of NHS patients and should be carried out by appropriately trained therapists or practitioners. It is however essential that the other componentsof treatment and management are also carried out by appropriately qualified therapists. We as chartered physiotherapists should be seen as the complete practitioner for providing services to patients with LBP combining manipulative skills in the restoration of normal pain-free function.
The October 1994 edition of Physiotherapy carried a centrepiece outlining the initiative taken by the Chartered Society of Physidherapy to combine the expertise of physiotherapists specialising in the treatment of patients with musculoskeletal dysfunction and the formation of the British Association of Chartered Physiotherapists in Manipulation (BACPIM). It is vital that there are enough physiotherapists with skills to provide comprehensive, accessible and equitably distributed services for all patients. Chartered physiotherapists are urged to take advantage of the conferences and courses provided by BACPIM in collaboration with the CSP. Physiotherapists must endeavour to ensure purchasers of their services - ie general practitioners, family health service authorities, trusts and health authorities - are aware of the comprehensive nature of their skills and that these are in line with the CSAG recommendations, This will facilitate the necessary redistribution of resources for the successful implementation of the recommendations. The CSAG report is interesting, highly informative and is essential reading for all physiotherapists involved in any way with the provision and implementation of services for patients with back pain - particularly the section entitled ‘Management Guidelines for Back Pain’.
Ann Thomson M S BA ~ MCSP mprrp Chairman, BACPIM ‘Back Pain: Report of a CSAG Committee on Back Pain chaired by Professor Michael Aosen (1994) HMSO. f14.95.
ISSN 0031 9406
Journal of The Chartered Society of Physiotherapy 14 Bedford Row, London WClR 4ED Telephone 071-242 1941 Fax 071-831 4509
BACK PAIN
- THE GROWING EPIDEMIC
Back pain has been a problem to mankind for as long as there are documented records. During the last decade it has reached epidemic proportions in the industrialised nations, resulting in escalating costa to the community. A comparison of Sickness and Invalidity Benefit for back incapacity (in Great Britain) between 1978/79 and 1991/92 indicates an increase of 208.5% whereas for all other musculoskeletal incapacities the increase is 136.4%.Circulatory diseases have increased by 9196, and mental disordersby 8496, while respiratory dieeaseshave decreased by 24.8%. During this time there have been various changes in the benefit regulations but these figures clearly illustrate the increasing prevalence of back pain. This and other aspects of the problem led the UK Health Ministers in 1992 to set up a Clinical Standards Advisory Group (CSAG) with the remit ‘to advise on standards of clinical care for, and access to and availability of services to NHS patients with back pain’. The committee decided to focus on acute low back pain (LBP) and set out to study epidemiology, the development of management guidelines, and the current NHS services, and to make recommendations on the future organisation of NHS services for patients with back pain. The CSAG report* was published in December 1994.In the report the value of physiotherapy is acknowledged both for the treatment of patients and for specialist secondary opinion. It is recommended that direct access to physiotherapy for GPs should be universally available, thus reducing the wastage of resources incurred when patients are inappropriately placed on waiting lists to see rheumatology or orthopaedic consultants in hospitals. The group recognises that effective implementation of the recommendations will lead to an increase in demand for physiotherapy services. This however should be made possible by redistribution of resources between primary and secondary care, rather than by any increase in funding.
Studies undertaken on behalf of the CSAG indicated that the annual cost of NHS services for back pain was approximately f 480 million in 1993; ca&a in lost production wem very approximately f3.8 billion and in DSS benefits f 1.4 billion. It seem possible thedore that there is a substantial impact to be made on the economic well being of the country as well as the reduction in misery and human suf€ering by accessible, high quality treatment from chartered physiotherapists. The CSAG representatives visited eight Health Districts and some of the findings were: .The NHS reforms were in general stimulating new and improved services for LBP (a point particularly welcomed by the Government!) OBest rest is not the answer. OTime spent on assessment reaps dividends. OPatients should be educated to be responsible for managing their own problem. OMore emphasis is needed on prevention. O G P referral to a physical therapist (physiotherapist, osteopath, chiropractor) will benefit patienta OAsian communitiee may be reluctant to be examined for LBI? OGW find it difficult to know which patients to refer to which therapist. O G P direct a c c w to physiotherapy in hospital or clinic can be achieved with short waiting times. .There is an emerging acceptance of the role of the practitioner physiotherapist in GP practices. O A second-opinion service for GPe could be physiotherapist led. OPhysiotherapiate, oeteopaths and chiropractors should collaborate in every District.
The report includes management guidelines which have been produced in collaboration with a panel in the US and are similar to Swedish guidelines. A careful history and examination is eesential and a diagnostic system is suggested to form the basis for decisions about management. The triage is simple backache, nerve root pain and possible serious spinal pathology. Diagnostic indicators are given for each, and should identify the small number of patients requiring urgent and emergency referral to a hospital specialist. An increased role and remurces are recommended for physical therapy for back pain, provided that resources are used to provide interventions of proven value. This constitutes an important challenge to chartered physiotherapists. In the report the term ‘physical therapy’ is used to denote osteopaths and chiropractors as well as physiotherapists and the recommendation is that
NHS patients may be treated by any one of the three professions subject to satisfactory audit. The interventions identified as being of ‘proven value’ are: 0 Manipulation 0 Active exercise and rehabilitation 0 Patient education and self-management 0 Prophylaxis. The report states that manipulation is seen as an effective method of providing symptomatic relief and should be available as a therapeutic option for the treatment of NHS patients and should be carried out by appropriately trained therapists or practitioners. It is however essential that the other componentsof treatment and management are also carried out by appropriately qualified therapists. We as chartered physiotherapists should be seen as the complete practitioner for providing services to patients with LBP combining manipulative skills in the restoration of normal pain-free function.
The October 1994 edition of Physiotherapy carried a centrepiece outlining the initiative taken by the Chartered Society of Physidherapy to combine the expertise of physiotherapists specialising in the treatment of patients with musculoskeletal dysfunction and the formation of the British Association of Chartered Physiotherapists in Manipulation (BACPIM). It is vital that there are enough physiotherapists with skills to provide comprehensive, accessible and equitably distributed services for all patients. Chartered physiotherapists are urged to take advantage of the conferences and courses provided by BACPIM in collaboration with the CSP. Physiotherapists must endeavour to ensure purchasers of their services - ie general practitioners, family health service authorities, trusts and health authorities - are aware of the comprehensive nature of their skills and that these are in line with the CSAG recommendations, This will facilitate the necessary redistribution of resources for the successful implementation of the recommendations. The CSAG report is interesting, highly informative and is essential reading for all physiotherapists involved in any way with the provision and implementation of services for patients with back pain - particularly the section entitled ‘Management Guidelines for Back Pain’.
Ann Thomson M S BA ~ MCSP mprrp Chairman, BACPIM ‘Back Pain: Report of a CSAG Committee on Back Pain chaired by Professor Michael Aosen (1994) HMSO. f14.95.