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Editorial
Pain 75 (1998) 163–168
Editorial
The socioeconomic impact of chronic back pain: is anyone benefiting? Steven J. Linton* ¨ rebro Medical Center, O ¨ rebro, Sweden Department of Occupational and Environmental Medicine, O Received 27 October 1997; received in revised form 1 December 1997; accepted 4 December 1997
1. Introduction Despite the well documented exorbitant costs of musculoskeletal pain, there is a need to take a broader view of its socioeconomic impact. Rather than simply lamenting skyrocketing expenditures, it may behove us to instead pose the question: Who is benefiting from the current state of affairs? In answering this question, I will attempt to illuminate the situation from several perspectives including the health-care system, and above all the individual and his/her family. All too often the health-care system or the individual patient seem to be blamed for the high costs, while the impact on these players themselves is not always highlighted.
2. The back pain problem Fig. 1 may be used to summarize the current problem of musculoskeletal pain as it shows the dramatically increasing number of sick days attributed to back pain in Britain (Waddell, 1996). Indeed, back and neck pain are leading causes of sick leave, compensation and early retirement expenditures in the West World (Nachemson, 1992; Skovron; 1992, Waddell, 1996). Health-care costs are also considerable. In the US the cost of treating low back pain alone is estimated to be several billion dollars and Deyo et al. (1991) point out that expenditures for low back pain are six times higher than for AIDS related ill-health. As a result, various changes in rules and laws governing care and compensation have been initiated, but they may have little influence on the experience of pain. For example, in Sweden recent legislative changes have reduced the number of injuries classified as work-related from some 80 000 in 1990 to about 9000 in 1996 (National Insurance Board, * Tel.: +46 19 152456; fax: +46 19 120404; e-mail: [email protected]
1997). Yet, epidemiological data from Finland show that despite changes in legislation, the economy, job market, etc. the prevalence of back pain has remained approximately the same over a 15-year period (Leino et al., 1978). While the life-time prevalence of back time has been found to be up to 85% of the population, most return to work rapidly (Nachemson, 1992; Waddell, 1996). Recent evidence from several studies shows that about 95% return to work within 6–12 weeks (Reid et al., 1997). This has lead to the misconception that people with acute back pain generally ‘recover’ within this time period. On the contrary, several longitudinal studies show that patients, on the average, still have considerable pain 6–12 months after seeking health-care for an acute episode (VonKorff, 1994; Linton and Hallde´n, 1997). Although back pain is very prevalent, a relatively small number of people consume the majority of the resources. In our own population-based study, we found that 6% of the sufferers consumed about half of the total health-care visits (Linton et al., 1998). There was also a relationship (r = 0.44) between those consuming health-care resources and sick leave demonstrating a tendency for the same people to be high consumers of several types of resources (Linton et al., 1998; Matheson and Brophy, 1997).
3. Expenditures for what? There is no doubt that a great deal of money is being spent on musculoskeletal pain problems and the costs appear to be increasing (Swedish Council on Technology Assessment in Health Care, 1991; Waddell, 1996). Since resources are explicitly limited, how are these resources being utilized? A recent study from the Netherlands sheds considerable light on this question. van Tulder et al. (1995) found that the cost of back pain alone was equal to 1.7% of the GNP, but that just 7% of the expenditures were spent on health-care. Indirect costs for absenteeism and disability amounted to
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93% of the total costs. Thus, while medical costs amounted to $368 million, the indirect costs associated with compensation were an astounding $4.6 billion. Absenteeism due to back pain costs the Netherlands an average of $1.5 million per hour! Although health-care costs for musculoskeletal pain in Sweden increased by nearly three fold between 1975 and 1983, the ‘proportion’ spent on health-care remained almost constant at 15% according to the National Board of Health and Welfare (1987). The remaining 85%, just as in the Netherlands, was spent on absenteeism and disability compensation. Unfortunately, the relatively small proportion of funds provided for health-care do not always seem to be placed on scientifically documented, modern, multidimensional pain management techniques. In the previously described study of health-care in the Netherlands (van Tulder et al., 1995), over half of the expenditures were related to hospital visits. This suggests the use of advanced diagnostic procedures and treatments. By contrast, only 6% of the healthcare costs were spent on the primary care level even though early, primary care based interventions are recommended (Swedish Council on Technology Assessment in Health Care, 1991; Agency for Health Care Policy and Research, 1994; Linton, 1994; VonKorff, 1994; Fordyce, 1995). A study of utilization shows that single modal treatments provided by doctors and physical therapists are the most frequently employed interventions (Nygren et al., 1996; van Tulder et al., 1997).
4. Impact on the individual The socioeconomic impact for the individual is often neglected and indeed, some descriptions of the problem leave the reader with a feeling that patients with back pain are eager to reap the ‘benefits’ of being sick. In fact, the term ‘compensation neurosis’ still exists as a concept and title of modern reports (Bellamy, 1997). Although compensation may influence behavior (Rohling et al., 1995), the question of how a musculoskeletal pain problem actually affects the individual remains. Important information on the impact for the individual is provided in a study of diabetics, hypertensives, healthy controls and those with musculoskeletal pain (Wa¨ndell et al., 1997). These researchers found that all three patient groups suffered considerable distress, e.g. feeling tired and worried, as compared to the healthy controls. In addition, the patient groups had a significantly lower income than the healthy controls. We have also been struck by the comparatively large number of people with long-term musculoskeletal pain having low incomes. The data of Wa¨ndell et al. (1997) suggest that patients with musculoskeletal pain suffer as much as the other long-term disease groups did. One might still argue that musculoskeletal pain is a part of life and thus should be relegated to what one should be
able to tolerate. Our own epidemiological study casts doubt on this idea as it demonstrates the amount of suffering involved. We surveyed a random selection of 35–45 year olds and found that 66% reported neck or back pain during the past year (Linton et al., 1998). However, 25% of those with pain had a ‘significant’ problem as determined by intense pain and activity hindrances. Despite this, sick leave, on the average, was low and many took vacation days etc. rather than miss work because of their pain. An investigation of 131 patients with fibromyalgia sheds further light on the economic impact on the individual patient (Goossens et al., 1996). This study meticulously kept track of all expenditures patients had using a weekly cost diary. They found that personal costs and out-of-pocket expenses accounted for 49% of the patient’s total health expenditures as compared to 51% for direct health-care costs. These patients, as an illustration, bought an average of 9.2 over-the-counter medicines during the year, paid for 21 h of professional help in the home and an additional 77 h of housekeeping. Not surprisingly then, Ferrell (1996) concludes that the economic impact of pain on the individual and family is striking as expenditures increase and income decreases.
5. Problem summary The problem then, is very prevalent and has great direct and indirect impact on society, the health-care system, and above all the individual and her/his family. The problem is usually recurrent in nature and a relatively small percent of sufferers consume large amounts of the resources. Musculoskeletal pain is expensive to treat when viewed in absolute costs. However, it is extraordinarily expensive to compensate sufferers for work loss because of the pain and there is a tremendous disproportion of expenditures where the vast majority is spent on compensation.
Fig. 1. Total number of days of sickness and invalidity benefits for back pain from 1955 to 1994 in the UK according to statistics from the Department of Social Security. Based on Waddell, 1996.
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Consequently, no one seems to be benefiting from the current situation. Given the thesis above, we may wonder why more resources are not being placed on modern pain management and rehabilitation services.
6. Rehabilitation and early treatment for prechronics? Since the large majority of costs are associated with work absenteeism and compensation benefits, we might presume that every effort is being made to rehabilitate these patients early on. The data however, paint a different picture. Again there is evidence that patients, even those with a considerable history of pain, will simply receive doctor’s care and possibly physical therapy or diagnostic examinations. Fig. 2 shows the percentage of patients in Sweden who have received an early treatment/rehabilitation for those with more than 3 months sick leave as well as those with a newly awarded disability pension (Nygren et al., 1996). An early rehabilitation was defined as a program offering a minimum of at least 4 h, 4 days a week for 2 weeks. As may be seen in Fig. 2 less than 25% had received this treatment even though both groups are high risk, high cost groups. A recent report from the Swedish National Social Insurance Authority (Marklund, 1997) supports this view showing that although there has been an increase since 1985, less than 20% of those with long-term sick absenteeism have received a rehabilitative intervention.
7. Is treatment cost-effective? One explanation for the small proportion of resources being spent on treatment relative to compensation might be that treatment is not effective. In fact, there appears to be a scepticism towards pain management and rehabilitation programs from various authorities as well as third party payers (Turk, 1996). Indeed, there are many different types of treatment for musculoskeletal pain and we have seen that health-care costs are substantial particularly for a small number of sufferers. Therefore, some treatment procedures may well lack in effectiveness. What is the situation
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for multidimensional pain management/rehabilitation facilities? An examination of major reviews shows that multidimensional pain rehabilitation programs are, on the whole, reasonably effective. Two meta-analyses of controlled trials demonstrate that multidimensional treatment is more effective than no treatment or single modal treatment (Flor et al., 1992; Cutler et al., 1994). Both conclude that patients receiving this treatment are roughly twice as likely to return-to-work. In 11 studies with control groups, Turk (1996) shows that while 67% of the patients treated at a multidimensional pain facility return to work, only 24% of the controls do so. Similarly, in Sweden a new review of a wide range of occupationally oriented rehabilitation programs shows that patients receiving this treatment have nearly a 50% better chance of being at work 6 months later than those not receiving rehabilitation treatment (Marklund, 1997). Two major economic evaluations of pain management programs moreover casts nails in the gears of sceptics. Turk (1996) examined the cost-benefit of multidisciplinary pain centers based on the effects reported in a meta-analytical review (Flor et al., 1992). He found that the total savings, based on the results of the meta-analysis, for reductions in surgery would be $33 million, while an additional $10 million would be saved in reduced medical costs. However, the largest savings would be a $175 million in reduced disability costs. He concludes that ‘…despite the criticisms and reservations raised, the body of literature available provides substantial evidence that multidimensional pain centers improve…objective measures, e.g. employment status, medication use, use of the health care system, and closure of disability cases…’ (Turk, 1996, p. 269). Since health economists may have a different view than Turk (a psychologist), and since his review is based on extrapolating costs and benefits rather than documented costs and savings, a recent review of studies that include an economic evaluation is of the utmost interest (Goossens and Evers, 1997). They identified 23 studies that conducted some sort of economic analysis. Although the authors find that the economic analyses could be methodologically improved, they conclude that ‘Injury prevention programs (except for back school programs) and post-incidence management programs appear to produce cost savings due to reduced absenteeism’ (p. 15). Thus, rather than focusing resources on compensation, many players in this arena might benefit from focusing more of the resources on pain management and rehabilitation programs.
8. The need for secondary prevention Fig. 2. Percent of men and women receiving rehabilitation for people on sick leave for 3 or more months as well as those with a recent disability pension. Based on Nygren et al., 1996.
What might be the most beneficial use of resources? While no one seems to be benefiting from the present situa-
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tion, many might benefit from high quality health-care applied at an early point in time. Although not always employed at an early time point, multidimensional programs may in fact be a real bargain since they usually focus on the small number of patients who tend to consume large amounts of the resources. Typically these patients have been off work or ill for at least 1 year and thus are consumers of large amounts of care and compensation. Quality pain management at the primary care level is another alternative that deserves more attention. This appears to be very promising as such interventions may prevent or reduce unnecessary suffering and associated health-care as well as absenteeism. In addition, such interventions are relatively inexpensive, and very safe. In contrast to the adage ‘too little, too late’, the idea is to provide better multidimensional care, a little earlier, and with better coordination with other agents, e.g. the workplace, insurance companies, and authorities. Although there may be debate on the most effective time point for intervention, providing the right treatment at the right time point seems extremely important. The recent New Zealand Guidelines call for very early evaluation of ‘yellow’ as well as the usual red flags (Kendall et al., 1997). The yellow flags represent the psychosocial dimension and are included since they appear to be potent risk factors for the development of chronic problems. The guidelines recommend that the yellow flags be included already at the first visit, and that a screening be conducted if the pain has not remitted by 2–4 weeks. This, however, is apparently a far cry from the current clinical situation. Admittedly many doctors are doing an excellent job, but still clinicians may not even pick-up intense acute back pain as a risk indicator. Reid et al. (1997) found, for example, that workers who report intense pain (.7, 0–10 scale) during the first 2 weeks were more likely to be on sick leave 3 months after injury. They emphasize that clinicians need to be sensitive to high acute pain ratings. Similarly, Dworkin (1997) argues that intense acute pain is an important potent risk factor that is often overlooked. Since acute musculoskeletal pain is not life-threatening and often remits, it may well be overlooked and underrated by clinicians (Linton, 1997). If a medical risk factor, e.g. pain intensity is being missed, what kind of a job is being done with ‘yellow flag’ risk factors? Nevertheless, some studies from primary care settings may serve as examples of the secondary prevention of long-term musculoskeletal pain problems. These programs have either been applied to all patients with musculoskeletal pain or they have keyed on the time factor such as selecting those off work more than a given number of weeks. For example, Ryan et al. (1995) compared the results of a secondary prevention program for all miners at a new facility with results at other similar mines. They provided an early medical examination, information, and assistance in returning to work. Supervisors were trained briefly in how to deal with back pain problems. Although this is not a randomized
study and may suffer from several sources of bias, they not only showed a significantly lower rate of work injuries and disability due to back pain, but during the 6-year trial not a single person in the experimental group developed a longterm problem. In general practice Fordyce et al. (1986) showed that a relatively simple program for dealing with acute back pain reduced disability one year later. Similarly, in our own research, we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8fold as compared to ‘treatment as usual’ (Linton et al., 1993). The program included a thorough examination by a doctor and physical therapist, information designed to reduce fear, uncertainty and anxiety, self-care recommendations, and the recommendation to remain active and continue everyday routines. Often patients applying for help are in the subacute stage. Furthermore, some authors argue that it is more effective to deal with patients in this stage since about 85% of those with acute pain will recover undramatically (Frank et al., 1996). Even here, there are examples of the potential benefits of simple, well-planned early interventions. Lindstro¨m et al. (1992) treated patients off work for 6 weeks with a specially devised program including a back school, work place examination, and above all a graded activity program. They showed large and significant decreases in sick leave as compared to a regular treatment control group. Finally, Indahl et al. (1995) provided a straight-forward and low cost intervention for people off work more than 8 weeks because of back pain. Firstly, they provided a ‘classic clinical examination by a physician’, tested physical capacity, and took X-rays. Then patients were informed about the findings and advise was provided. Patients were told that ‘light activity’ would not injure the disc, but instead would speed recovery. They placed great emphasis on removing fear about the back pain and specific recommendations about movements were provided. In a randomized clinical trial this ‘minimal’ treatment was shown to significantly reduce sick leave as compared to the control group and the return-to-work rate was more than twice as high in this intervention group. There seems to be several common denominators in the above programs. Firstly, they appear to take a multidimensional view of the problem. A major emphasis is placed on psychosocial aspects of the problem, e.g. the fear and worry involved. Secondly, a thorough, but ‘low-tech’ examination is provided. Thirdly, after the examination, time is taken to communicate the results, e.g. why it hurts and provide advice as to how the problem may be best managed. Fourthly, there is an emphasis on self-care, i.e. that the patient’s behavior is an integral part in the recovery process. Pain management is a vital aspect as pharmacological and nonpharmacological methods may be useful. Reducing the pain would also appear to lessen fear and other psychological factors that may fuel long-term problems. Fifthly, there
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is an attempt to reduce any unfounded fear or anxiety concerning the pain. Sixthly, the programs provide crystal clear recommendations concerning activities and in some cases help patients regain function by providing graded exercises. Lastly, what the programs do not do is medicalize the pain, e.g. by the indiscriminant use of high tech exams, referrals as a starting point, sick certificates of more than a few days; providing extensive prescriptions, or advising the patient to ‘take it easy’ or bed rest. The extra time involved in providing the programs varies greatly. Indahl apparently used four contacts, and our own study used an average of three while Fordyce apparently did not use any ‘extra’ sessions, but the length of each visit may have been longer. Nevertheless, I argue that the above aspects are a part of quality care rather than ‘extras’ and moreover that they probably are costeffective since they may reduce long-term suffering, health care utilization, and sick absenteeism.
Acknowledgements This is a version of a paper presented at the Pain in Europe Conference of the European Federation of IASP Chapters held in Barcelona in September, 1997. My sincere thanks to Professor Iain Crombie for his helpful comments and encouragement. This work was supported in part by a grant from the Swedish Council for Work Life Research. References Agency for Health Care Policy and Research, Clinical Practice Guidelines Number 14: Acute Low Back Problems in Adults, US Department of Health and Human Services, Rockville, MD, 1994. Bellamy, R., Compensation neurosis, Clin. Orthop. Rel. Res., 336 (1997) 94–106. Cutler, R.B., Fishbain, D.A., Rosomoff, H.L., Abdel-Moty, E., Khalil, T.M. and Rosomoff, R.S., Does nonsurgical pain center treatment of chronic pain return patients to work? A review and meta-analysis of the literature, Spine, 19 (1994) 643–652. Deyo, R., Cherkin, D., Conrad, D. and Volinn, E., Cost, controversy, crisis: low back pain and the health of the public, Annu. Rev. Public Health, 12 (1991) 141–156. Dworkin, R.H., Which individuals with acute pain are most likely to develop a chronic pain syndrome?, Pain Forum, 6 (1997) 127– 136. Ferrell, B.R., How patients and families pay the price of pain. In: M.J.M. Cohen and J.N. Campbell (Eds.), Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal, Vol. 7, IASP Press, Seattle, WA, 1996, pp. 229–237. Flor, H., Fydrich, T. and Turk, D.C., Efficacy of multidisciplinary pain treatment centers: A meta-analytic review, Pain, 49 (1992) 221– 230. Fordyce, W.E., Brockway, J.A., Bergman, J.A. and Spengler, D., Acute back pain: a control-group comparison of behavioral vs traditional managment methods, J. Behav. Med., 9 (1986) 127–140. Fordyce, W.E., Back pain in the workplace: management of disability in nonspecific conditions. A report of the Task Force on Pain in the Workplace of the IASP, IASP Press, Seattle, WA, 1995, 75 pp. Frank, J.W., Brooker, A.S., DeMaio, S.E., Kerr, M.S., Maetzel, A., Shannon, H.S., Sullivan, T.J., Norman, R.W. and Wells, R.P., Disability
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resulting from occupational low back pain: Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins, Spine, 21 (1996) 2918–2929. Goossens, M.E.J.B. and Evers, S.M.A.A., Economic evaluation of back pain interventions, J. Occup. Rehab., 7 (1997) 15–32. Goossens, M.E.J.B., Rutten-van Mo¨lken, M.P.M.H., Leidl, R.M., Bos, S.G.P.M., Vlaeyen, J.W.S. and Teeken-Gruben, N.J.G., Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. II. Economic evaluation, J. Rheumatol., 23 (1996) 1246–1254. Indahl, A., Velund, L. and Reikeraas, O., Good prognosis for low back pain when left untampered: A randomized clinical trial, Spine, 20 (1995) 473–477. Kendall, N.A.S., Linton, S.J. and Main, C.J., Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long-term disability and work loss, Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee, Wellington, New Zealand, 1997. Leino, P.I., Berg, M.A. and Puska, P., Is back pain increasing? Results from national surveys in Finland during 1978/9-1992, Scand. J. Rheumatol., 23 (1994) 269–276. ¨ hlund, C., Eek, C., Wallin, L., Peterson, L.E., Fordyce, Lindstro¨m, I., O W.E. and Nachemson, A.L., The effect of graded activity on patients with subacute low back pain: A randomized prospective clinical study with an operant-conditioning behavioral approach, Phys. Ther., 72 (1992) 279–293. Linton, S.J., The challenge of preventing chronic musculoskeletal pain. In: G.F. Gebhart, D.L. Hammond and T.S. Jensen (Eds.), Proceedings of the 7th World Congress on Pain: Progress in Pain and Research Management, Vol. 2, IASP Press, Seattle, WA, 1994, pp. 149–166. Linton, S.J., Overlooked and underrated? The role of acute pain intensity in the development of chronic back pain problems, Pain Forum, 6 (1997) 145–147. Linton, S.J. and Hallde´n, K., Risk factors and the natural course of acute and recurrent musculoskeletal pain: developing a screening instrument. In: T.S. Jensen, J.A. Turner and Z. Wiesenfeld-Hallin (Eds.), Proceedings of the 8th World Congress on Pain, Vol. 8, IASP Press, Seattle, WA, 1997, pp. 527–536. Linton, S.J., Hellsing, A.L. and Andersson, D., A controlled study of the effects of an early intervention on acute musculoskeletal pain problems, Pain, 54 (1993) 353–359. Linton, S.J., Hellsing, A.L. and Hallde´n, K., A population based study of spinal pain among 35–45-year-olds: prevalence, sick leave, and healthcare utilization, Spine, (1998) in press. Marklund, S., Risk och frisk faktorer: sjukskrivning och rehabilitering i Sverige (Sickness Absenteeism and Vocational Rehabilitation in Sweden: A Summary), Riksfo¨rsa¨kringsverket, Stockholm, 1997. Matheson, L.N. and Brophy, R.G., Aggressive early intervention after occupational back injury: Some preliminary observations, J. Occup. Rehab., 7 (1997) 107–117. Nachemson, A.L., Newest knowledge of low back pain, Clin. Orthop., 279 (1992) 8–20. National Board of Health and Welfare, Att fo¨rebygga sjukdomar i ro¨relseorganen (Preventing musculoskeletal pain), Socialstyrelsen, Stockholm, 1987. National Insurance Board, Arbetsskador: anma¨lningar fo¨r pro¨vning (Workrelated injuries: applications), Riksfo¨rsa¨kringsverket Informerar, 8, 1997. ˚ ., Jensen, I., Bergstro¨m, G. and Ljungkvist, T., Nacke-ryggNygren, A ˚ . Nygren, I. Jensen, L. Andersson besva¨r (Neck and back pain). In: A and J. Lisspers (Eds.), Ha¨lsoekonomisk utva¨rdering av rehabilitering (Economic evaluation of rehabilitation, Department of Accident Prevention, Karolinska Institute, Stockholm, 1996, pp. 6–14. Reid, S., Haugh, L.D., Hazard, R.G. and Tripathi, M., Occupational low back pain: recovery curves and factors associated with disability, J. Occup. Rehab., 7 (1997) 1–14. Rohling, M.L., Binder, L.M. and Langhinrichsen-Rohling, J., Money matters: a meta-analytic review of the association between financial com-
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pensation and the experience and treatment of chronic pain, Health Psychol., 14 (1995) 537–547. Ryan, W.E., Krishna, M.K. and Swanson, C.E., A prospective study evaluating early rehabilitation in preventing back pain chronicity in mine workers, Spine, 20 (1995) 489–491. Skovron, M.L., Epidemiology of low back pain, Baillie`re’s Clin. Rheumatol., 6 (1992) 559–573. Swedish Council on Technology Assessment in Health Care, Back pain: causes, diagnostics and treatment, Swedish Council on Technology Assessment in Health Care, Stockholm, 1991, 200 pp. Turk, D.C., Efficacy of multidisciplinary pain centers in the treatment of chronic pain. In: M.J.M. Cohen and J.N. Campbell (Eds.), Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal, Vol. 7, IASP Press, Seattle, WA, 1996, pp. 257–273.
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Editorial
The socioeconomic impact of chronic back pain: is anyone benefiting? Steven J. Linton* ¨ rebro Medical Center, O ¨ rebro, Sweden Department of Occupational and Environmental Medicine, O Received 27 October 1997; received in revised form 1 December 1997; accepted 4 December 1997
1. Introduction Despite the well documented exorbitant costs of musculoskeletal pain, there is a need to take a broader view of its socioeconomic impact. Rather than simply lamenting skyrocketing expenditures, it may behove us to instead pose the question: Who is benefiting from the current state of affairs? In answering this question, I will attempt to illuminate the situation from several perspectives including the health-care system, and above all the individual and his/her family. All too often the health-care system or the individual patient seem to be blamed for the high costs, while the impact on these players themselves is not always highlighted.
2. The back pain problem Fig. 1 may be used to summarize the current problem of musculoskeletal pain as it shows the dramatically increasing number of sick days attributed to back pain in Britain (Waddell, 1996). Indeed, back and neck pain are leading causes of sick leave, compensation and early retirement expenditures in the West World (Nachemson, 1992; Skovron; 1992, Waddell, 1996). Health-care costs are also considerable. In the US the cost of treating low back pain alone is estimated to be several billion dollars and Deyo et al. (1991) point out that expenditures for low back pain are six times higher than for AIDS related ill-health. As a result, various changes in rules and laws governing care and compensation have been initiated, but they may have little influence on the experience of pain. For example, in Sweden recent legislative changes have reduced the number of injuries classified as work-related from some 80 000 in 1990 to about 9000 in 1996 (National Insurance Board, * Tel.: +46 19 152456; fax: +46 19 120404; e-mail: [email protected]
1997). Yet, epidemiological data from Finland show that despite changes in legislation, the economy, job market, etc. the prevalence of back pain has remained approximately the same over a 15-year period (Leino et al., 1978). While the life-time prevalence of back time has been found to be up to 85% of the population, most return to work rapidly (Nachemson, 1992; Waddell, 1996). Recent evidence from several studies shows that about 95% return to work within 6–12 weeks (Reid et al., 1997). This has lead to the misconception that people with acute back pain generally ‘recover’ within this time period. On the contrary, several longitudinal studies show that patients, on the average, still have considerable pain 6–12 months after seeking health-care for an acute episode (VonKorff, 1994; Linton and Hallde´n, 1997). Although back pain is very prevalent, a relatively small number of people consume the majority of the resources. In our own population-based study, we found that 6% of the sufferers consumed about half of the total health-care visits (Linton et al., 1998). There was also a relationship (r = 0.44) between those consuming health-care resources and sick leave demonstrating a tendency for the same people to be high consumers of several types of resources (Linton et al., 1998; Matheson and Brophy, 1997).
3. Expenditures for what? There is no doubt that a great deal of money is being spent on musculoskeletal pain problems and the costs appear to be increasing (Swedish Council on Technology Assessment in Health Care, 1991; Waddell, 1996). Since resources are explicitly limited, how are these resources being utilized? A recent study from the Netherlands sheds considerable light on this question. van Tulder et al. (1995) found that the cost of back pain alone was equal to 1.7% of the GNP, but that just 7% of the expenditures were spent on health-care. Indirect costs for absenteeism and disability amounted to
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93% of the total costs. Thus, while medical costs amounted to $368 million, the indirect costs associated with compensation were an astounding $4.6 billion. Absenteeism due to back pain costs the Netherlands an average of $1.5 million per hour! Although health-care costs for musculoskeletal pain in Sweden increased by nearly three fold between 1975 and 1983, the ‘proportion’ spent on health-care remained almost constant at 15% according to the National Board of Health and Welfare (1987). The remaining 85%, just as in the Netherlands, was spent on absenteeism and disability compensation. Unfortunately, the relatively small proportion of funds provided for health-care do not always seem to be placed on scientifically documented, modern, multidimensional pain management techniques. In the previously described study of health-care in the Netherlands (van Tulder et al., 1995), over half of the expenditures were related to hospital visits. This suggests the use of advanced diagnostic procedures and treatments. By contrast, only 6% of the healthcare costs were spent on the primary care level even though early, primary care based interventions are recommended (Swedish Council on Technology Assessment in Health Care, 1991; Agency for Health Care Policy and Research, 1994; Linton, 1994; VonKorff, 1994; Fordyce, 1995). A study of utilization shows that single modal treatments provided by doctors and physical therapists are the most frequently employed interventions (Nygren et al., 1996; van Tulder et al., 1997).
4. Impact on the individual The socioeconomic impact for the individual is often neglected and indeed, some descriptions of the problem leave the reader with a feeling that patients with back pain are eager to reap the ‘benefits’ of being sick. In fact, the term ‘compensation neurosis’ still exists as a concept and title of modern reports (Bellamy, 1997). Although compensation may influence behavior (Rohling et al., 1995), the question of how a musculoskeletal pain problem actually affects the individual remains. Important information on the impact for the individual is provided in a study of diabetics, hypertensives, healthy controls and those with musculoskeletal pain (Wa¨ndell et al., 1997). These researchers found that all three patient groups suffered considerable distress, e.g. feeling tired and worried, as compared to the healthy controls. In addition, the patient groups had a significantly lower income than the healthy controls. We have also been struck by the comparatively large number of people with long-term musculoskeletal pain having low incomes. The data of Wa¨ndell et al. (1997) suggest that patients with musculoskeletal pain suffer as much as the other long-term disease groups did. One might still argue that musculoskeletal pain is a part of life and thus should be relegated to what one should be
able to tolerate. Our own epidemiological study casts doubt on this idea as it demonstrates the amount of suffering involved. We surveyed a random selection of 35–45 year olds and found that 66% reported neck or back pain during the past year (Linton et al., 1998). However, 25% of those with pain had a ‘significant’ problem as determined by intense pain and activity hindrances. Despite this, sick leave, on the average, was low and many took vacation days etc. rather than miss work because of their pain. An investigation of 131 patients with fibromyalgia sheds further light on the economic impact on the individual patient (Goossens et al., 1996). This study meticulously kept track of all expenditures patients had using a weekly cost diary. They found that personal costs and out-of-pocket expenses accounted for 49% of the patient’s total health expenditures as compared to 51% for direct health-care costs. These patients, as an illustration, bought an average of 9.2 over-the-counter medicines during the year, paid for 21 h of professional help in the home and an additional 77 h of housekeeping. Not surprisingly then, Ferrell (1996) concludes that the economic impact of pain on the individual and family is striking as expenditures increase and income decreases.
5. Problem summary The problem then, is very prevalent and has great direct and indirect impact on society, the health-care system, and above all the individual and her/his family. The problem is usually recurrent in nature and a relatively small percent of sufferers consume large amounts of the resources. Musculoskeletal pain is expensive to treat when viewed in absolute costs. However, it is extraordinarily expensive to compensate sufferers for work loss because of the pain and there is a tremendous disproportion of expenditures where the vast majority is spent on compensation.
Fig. 1. Total number of days of sickness and invalidity benefits for back pain from 1955 to 1994 in the UK according to statistics from the Department of Social Security. Based on Waddell, 1996.
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Consequently, no one seems to be benefiting from the current situation. Given the thesis above, we may wonder why more resources are not being placed on modern pain management and rehabilitation services.
6. Rehabilitation and early treatment for prechronics? Since the large majority of costs are associated with work absenteeism and compensation benefits, we might presume that every effort is being made to rehabilitate these patients early on. The data however, paint a different picture. Again there is evidence that patients, even those with a considerable history of pain, will simply receive doctor’s care and possibly physical therapy or diagnostic examinations. Fig. 2 shows the percentage of patients in Sweden who have received an early treatment/rehabilitation for those with more than 3 months sick leave as well as those with a newly awarded disability pension (Nygren et al., 1996). An early rehabilitation was defined as a program offering a minimum of at least 4 h, 4 days a week for 2 weeks. As may be seen in Fig. 2 less than 25% had received this treatment even though both groups are high risk, high cost groups. A recent report from the Swedish National Social Insurance Authority (Marklund, 1997) supports this view showing that although there has been an increase since 1985, less than 20% of those with long-term sick absenteeism have received a rehabilitative intervention.
7. Is treatment cost-effective? One explanation for the small proportion of resources being spent on treatment relative to compensation might be that treatment is not effective. In fact, there appears to be a scepticism towards pain management and rehabilitation programs from various authorities as well as third party payers (Turk, 1996). Indeed, there are many different types of treatment for musculoskeletal pain and we have seen that health-care costs are substantial particularly for a small number of sufferers. Therefore, some treatment procedures may well lack in effectiveness. What is the situation
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for multidimensional pain management/rehabilitation facilities? An examination of major reviews shows that multidimensional pain rehabilitation programs are, on the whole, reasonably effective. Two meta-analyses of controlled trials demonstrate that multidimensional treatment is more effective than no treatment or single modal treatment (Flor et al., 1992; Cutler et al., 1994). Both conclude that patients receiving this treatment are roughly twice as likely to return-to-work. In 11 studies with control groups, Turk (1996) shows that while 67% of the patients treated at a multidimensional pain facility return to work, only 24% of the controls do so. Similarly, in Sweden a new review of a wide range of occupationally oriented rehabilitation programs shows that patients receiving this treatment have nearly a 50% better chance of being at work 6 months later than those not receiving rehabilitation treatment (Marklund, 1997). Two major economic evaluations of pain management programs moreover casts nails in the gears of sceptics. Turk (1996) examined the cost-benefit of multidisciplinary pain centers based on the effects reported in a meta-analytical review (Flor et al., 1992). He found that the total savings, based on the results of the meta-analysis, for reductions in surgery would be $33 million, while an additional $10 million would be saved in reduced medical costs. However, the largest savings would be a $175 million in reduced disability costs. He concludes that ‘…despite the criticisms and reservations raised, the body of literature available provides substantial evidence that multidimensional pain centers improve…objective measures, e.g. employment status, medication use, use of the health care system, and closure of disability cases…’ (Turk, 1996, p. 269). Since health economists may have a different view than Turk (a psychologist), and since his review is based on extrapolating costs and benefits rather than documented costs and savings, a recent review of studies that include an economic evaluation is of the utmost interest (Goossens and Evers, 1997). They identified 23 studies that conducted some sort of economic analysis. Although the authors find that the economic analyses could be methodologically improved, they conclude that ‘Injury prevention programs (except for back school programs) and post-incidence management programs appear to produce cost savings due to reduced absenteeism’ (p. 15). Thus, rather than focusing resources on compensation, many players in this arena might benefit from focusing more of the resources on pain management and rehabilitation programs.
8. The need for secondary prevention Fig. 2. Percent of men and women receiving rehabilitation for people on sick leave for 3 or more months as well as those with a recent disability pension. Based on Nygren et al., 1996.
What might be the most beneficial use of resources? While no one seems to be benefiting from the present situa-
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tion, many might benefit from high quality health-care applied at an early point in time. Although not always employed at an early time point, multidimensional programs may in fact be a real bargain since they usually focus on the small number of patients who tend to consume large amounts of the resources. Typically these patients have been off work or ill for at least 1 year and thus are consumers of large amounts of care and compensation. Quality pain management at the primary care level is another alternative that deserves more attention. This appears to be very promising as such interventions may prevent or reduce unnecessary suffering and associated health-care as well as absenteeism. In addition, such interventions are relatively inexpensive, and very safe. In contrast to the adage ‘too little, too late’, the idea is to provide better multidimensional care, a little earlier, and with better coordination with other agents, e.g. the workplace, insurance companies, and authorities. Although there may be debate on the most effective time point for intervention, providing the right treatment at the right time point seems extremely important. The recent New Zealand Guidelines call for very early evaluation of ‘yellow’ as well as the usual red flags (Kendall et al., 1997). The yellow flags represent the psychosocial dimension and are included since they appear to be potent risk factors for the development of chronic problems. The guidelines recommend that the yellow flags be included already at the first visit, and that a screening be conducted if the pain has not remitted by 2–4 weeks. This, however, is apparently a far cry from the current clinical situation. Admittedly many doctors are doing an excellent job, but still clinicians may not even pick-up intense acute back pain as a risk indicator. Reid et al. (1997) found, for example, that workers who report intense pain (.7, 0–10 scale) during the first 2 weeks were more likely to be on sick leave 3 months after injury. They emphasize that clinicians need to be sensitive to high acute pain ratings. Similarly, Dworkin (1997) argues that intense acute pain is an important potent risk factor that is often overlooked. Since acute musculoskeletal pain is not life-threatening and often remits, it may well be overlooked and underrated by clinicians (Linton, 1997). If a medical risk factor, e.g. pain intensity is being missed, what kind of a job is being done with ‘yellow flag’ risk factors? Nevertheless, some studies from primary care settings may serve as examples of the secondary prevention of long-term musculoskeletal pain problems. These programs have either been applied to all patients with musculoskeletal pain or they have keyed on the time factor such as selecting those off work more than a given number of weeks. For example, Ryan et al. (1995) compared the results of a secondary prevention program for all miners at a new facility with results at other similar mines. They provided an early medical examination, information, and assistance in returning to work. Supervisors were trained briefly in how to deal with back pain problems. Although this is not a randomized
study and may suffer from several sources of bias, they not only showed a significantly lower rate of work injuries and disability due to back pain, but during the 6-year trial not a single person in the experimental group developed a longterm problem. In general practice Fordyce et al. (1986) showed that a relatively simple program for dealing with acute back pain reduced disability one year later. Similarly, in our own research, we found that a secondary prevention program in primary care, for first time sufferers, significantly reduced disability and reduced the risk of becoming chronic by 8fold as compared to ‘treatment as usual’ (Linton et al., 1993). The program included a thorough examination by a doctor and physical therapist, information designed to reduce fear, uncertainty and anxiety, self-care recommendations, and the recommendation to remain active and continue everyday routines. Often patients applying for help are in the subacute stage. Furthermore, some authors argue that it is more effective to deal with patients in this stage since about 85% of those with acute pain will recover undramatically (Frank et al., 1996). Even here, there are examples of the potential benefits of simple, well-planned early interventions. Lindstro¨m et al. (1992) treated patients off work for 6 weeks with a specially devised program including a back school, work place examination, and above all a graded activity program. They showed large and significant decreases in sick leave as compared to a regular treatment control group. Finally, Indahl et al. (1995) provided a straight-forward and low cost intervention for people off work more than 8 weeks because of back pain. Firstly, they provided a ‘classic clinical examination by a physician’, tested physical capacity, and took X-rays. Then patients were informed about the findings and advise was provided. Patients were told that ‘light activity’ would not injure the disc, but instead would speed recovery. They placed great emphasis on removing fear about the back pain and specific recommendations about movements were provided. In a randomized clinical trial this ‘minimal’ treatment was shown to significantly reduce sick leave as compared to the control group and the return-to-work rate was more than twice as high in this intervention group. There seems to be several common denominators in the above programs. Firstly, they appear to take a multidimensional view of the problem. A major emphasis is placed on psychosocial aspects of the problem, e.g. the fear and worry involved. Secondly, a thorough, but ‘low-tech’ examination is provided. Thirdly, after the examination, time is taken to communicate the results, e.g. why it hurts and provide advice as to how the problem may be best managed. Fourthly, there is an emphasis on self-care, i.e. that the patient’s behavior is an integral part in the recovery process. Pain management is a vital aspect as pharmacological and nonpharmacological methods may be useful. Reducing the pain would also appear to lessen fear and other psychological factors that may fuel long-term problems. Fifthly, there
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is an attempt to reduce any unfounded fear or anxiety concerning the pain. Sixthly, the programs provide crystal clear recommendations concerning activities and in some cases help patients regain function by providing graded exercises. Lastly, what the programs do not do is medicalize the pain, e.g. by the indiscriminant use of high tech exams, referrals as a starting point, sick certificates of more than a few days; providing extensive prescriptions, or advising the patient to ‘take it easy’ or bed rest. The extra time involved in providing the programs varies greatly. Indahl apparently used four contacts, and our own study used an average of three while Fordyce apparently did not use any ‘extra’ sessions, but the length of each visit may have been longer. Nevertheless, I argue that the above aspects are a part of quality care rather than ‘extras’ and moreover that they probably are costeffective since they may reduce long-term suffering, health care utilization, and sick absenteeism.
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