1
Economic Issues, Risk Factors, and Litigation

Marco Brayda-Bruno

■ Introduction

The epidemiological burden of low back pain (LBP) and its socioeconomic impact in developed countries have been well analyzed and widely discussed in the past 40 years. Hundreds of basic research studies, clinical studies, multidisciplinary treatment proposals, analytic epidemiology papers, book chapters, and review articles have addressed this crucial problem. Low back pain (LBP), particularly in its chronic phenotype (CLBP), diminishes the patients’ quality of life (QoL), with major consequences for their careers and social activities. In my 30 years of experience as a spine specialist, not much has changed in our understanding of the epidemiology of, risk factors for, and treatment of back pain.

Recent epidemiological research suggests that LBP is a leading cause of disability.¹ It presents a substantial societal burden in terms of health care costs and reduced work productivity to the tune of billions of dollars annually in many western countries. Lifetime prevalence rates of LBP are high, and a significant proportion of patients develop chronic symptoms lasting 3 months or longer. Chronic LBP results in extensive personal suffering and substantial economic costs for patients and society.

■ Background

Forty Years Ago

In a milestone paper published in the first issue of Spine in March 1976, Alf Nachemson² presented the issues and controversies in the treatment of LBP that have continued to be discussed by practitioners and researchers in the following decades:

Low back pain is, in patients aged 30 to 60 years, the most expensive ailment from a socio-economic viewpoint. . . . At present the etiology is unknown . . . and only symptomatic treatment is available. . . . So far no convincing evidence exists that any type of conservative treatment for the patient with low back pain is superior to nature’s own course…. There are no more than 50 scientists in the world today at work on elucidating the cause of our most expensive disease. This is truly the orthopaedic superchallenge.²

Has the situation changed much since that paper was published? Certainly the number of researchers, clinicians, and surgeons engaged in LBP issues has increased tremendously, but it is not clear that this work has resulted in a definitive improvement in LBP patients’ perceived QoL or in a reduction in the costs to society.

An editorial in Acta Orthopaedica Scandinavica entitled “The Back Pain Epidemic”3 addressed the medico-social paradox of back pain: “Disability due to backache has reached epidemic proportion while heavy physical labor has decreased dramatically” in modern western countries. The editorial went on to state that the basic cause of CLBP

is not due to physical work-related factors or to a universal weakening of the locomotor system. Rather, the culprits are (a) the idea that back problems generally improve with rest, and (b) the social-security reaction to this idea with prolonged sick leave and early retirement.³

Twenty Years Ago

In view of its high prevalence in developed countries, its heavy psychosocial and financial burden, and the burden imposed on health services, CLBP has become a severe public health problem. Consequently, the World Health Organization (WHO) established in the 1990s a working group to address the main diagnostic issues related to LBP and to review the epidemiology. Analyzing data obtained from the International Classification of Diseases (ICD-10) in 1993, the WHO report concluded that “low back pain is a general symptom” in at least 18 diagnostic categories!⁴

The Present

Despite recent advances in technology that have aided diagnosis and treatment, as well as the abundance of epidemiological studies in the literature, no definitive solution for LBP has been proposed, and it continues to have a severe impact on the individual, the family, and society.

■ Epidemiology, Prevalence, Incidence, and Persistence and Recurrence of Low Back Pain

Box 1.1 provides definitions of epidemiology, prevalence, incidence, and persistence and recurrence. The following text subsections address these concepts with regard to LBP.

Incidence

The 1-year incidence of a first-ever episode of LBP ranges between 6.3% and 15.4%, whereas estimates of the 1-year incidence of any episode of LBP range between 1.5% and 36%. Meta-analytical incidence rates for first-time LBP and transition to pain from a pain-free state were similar (~ 25%), regardless of the community or occupational population.⁵ Estimates of recurrence at 1 year range from 24% to 80%.

Prevalence

About 75 to 85% of all individuals will experience LBP at some point in their lifetime (lifetime prevalence). The yearly prevalence of back pain is estimated to range from 15 to 20% in the United States and from 25 to 45% in Europe. The prevalence of LBP was higher among women than among men. LBP was observed more frequently among older people and among those who were overweight.

In the 1980s, Gordon Waddell6 distinguished acute/subacute LBP from chronic LBP:

CLBP is a completely different clinical syndrome from acute back pain, not only in time scale as per definition, but in kind. While acute pain could be relieved with efficacy if the underlying physical disorder is treated, chronic LBP becomes progressively dissociated from its original physical basis. The subsequent chronic disability and illness behaviour are increasingly coped with emotional distress, depression, and adoption of a sick role. CLBP becomes a self-sustaining condition that could be resistant to any medical management.

A very important contribution to our understanding of LBP and to the classification of the epidemiological characteristics of LBP was a 1988 article in the New England Journal of Medicine by John Frymoyer⁷ that proposed the following definitions of acute, subacute, and chronic LBP, which subsequently were widely adopted: Acute LBP lasts up to 6 weeks and is generally unspecific, with only 10 to 20% of cases having a precise pathoanatomic cause. Subacute LBP lasts more than 6 weeks and up to 3 months; its cause is often elusive. Acute and subacute backache are transitory symptoms, having resolution within 2 months in 90% of patients. Chronic LBP lasts longer than 3 months. It occurs in 5% of patients, and accounts for 85% of the social costs in terms of reduced work productivity and lost compensation.

These findings have been frequently questioned, as the condition tends to relapse, and most patients experience multiple episodes years after the initial attack.

With respect to the cause of back pain, the so-called diagnostic triage classification has become standard. It categorizes LBP as (1) a specific spinal pathology, (2) nerve root pain/ radicular pain, or (3) nonspecific.⁸

■ Pain, Impairment, and Disability

The Glasgow Illness Model (Fig. 1.1) is an operational clinical model of low back disability that includes physical, psychological, and social elements. It assumes that most back and neck pain starts with a physical problem, which causes nociception, at least initially. Psychological distress may significantly amplify the subjective pain experience and lead to abnormal illness behavior. This distress could alter social functions, and the individual may adopt the role of being a sick person; a small minority of patients with this “sick role” experience high levels of pain, even though the initial cause of nociception should have ceased and healing should have occurred.⁸

Fig. 1.1 The Glasgow Illness Model of Disability is an operational model of low back pain disability, as it develops from a physical problem to an illness behavior to a social sick role. (From Boos N, Aebi M, eds. Spinal Disorders: Fundamentals of Diagnosis and Treatment. Berlin: Springer; 2008. Reprinted by permission.)

There are multiple physical and psychosocial risk factors for a first-time LBP, but a history of a previous episode of back pain is by far the most strongly predictive and consistent risk factor for transition from a pain-free state to CLBP.9

Genetics

The genetic predisposition is clearly evident in disk degeneration, whereas the genetic predisposition in back pain is less clear and seems to depend on age. The influence of genetic predisposition has been established in several studies and in such multicenter European studies as Eurodisc and Genodics. It is likely that many genes are involved, and we are only beginning to unravel the molecular background of pain. Genetic factors could also affect pain perception. With the advance of molecular biological techniques, research has focused on exploring the genetic predisposition of interindividual differences. The influence on back pain, therefore, might be indirect, via spine morphological factors, or via a genetically determined tendency for psychological distress.8

Other individual characteristics indicating a susceptibility to spinal disorders include advanced age (> 50 years) and gender: females are more susceptible than males, but males are more likely to have a higher number of absences from work

Age and Gender

Hoy et al,¹⁰ in a recent systematic review of the global prevalence of LBP, analyzed 165 general population studies from 54 countries, published between 1980 and 2009. LBP was shown to be a major problem throughout the world, with the highest prevalence among females and those of ages 40 to 80 years. Other studies have found that the incidence of LBP is highest in the third decade of life, whereas overall prevalence increases with age until the 60- to 65-year age group, and then gradually declines. Thus, as the population ages, the number of individuals with LBP worldwide is likely to increase substantially over the coming decades, as confirmed also by the study of Ghanei et al¹¹ that has shown a 1-year prevalence of LBP of close to 50% in community-living men of ages 69 to 81 years.

Many other environmental and personal risk factors may influence the onset and course of LBP. Being overweight, having a lower general health status and more comorbidities, smoking, and leading a sedentary lifestyle could be risk factors for LBP.

Morphological Factors

In the past, anatomic anomalies and structural spine modifications, together with their consequent mechanical or inflammatory processes, were thought to be crucial factors in causing back pain.² But now we know that such morphological factors are poorly correlated with LBP. Disk herniation or degeneration is often present in asymptomatic individuals; spina bifida, transitional vertebrae, spondylosis, and Scheuermann’s disease do not appear to be associated with specific LBP. Similarly, patients with spondylolysis and spondylolisthesis are often considered to have nonspecific LBP.⁸

From an anatomic point of view, LBP commonly appears as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). Pain location is fairly consistent, with the immediate paraspinal region being the most common.

Psychosocial Factors

Since the very first studies on LBP,² psychosocial factors were known to influence low back disability, and, in accordance with the Glasgow Illness Model, recent epidemiological research confirms that these factors are an integral part of the pain disability process and have more impact on LBP disability than do biomechanical factors. Depression and anxiety are the most studied risk factors, and there is strong evidence that psychosocial variables are associated with the transition from acute to chronic pain and disability; inappropriate attitudes and beliefs about LBP, inappropriate pain behavior, low work satisfaction, and emotional problems are strongly linked to the development of chronic pain.⁸

Occupational Physical Factors

Heavy physical work is associated with LBP; in the past, it was considered as a major factor in inducing back pain,² but there is evidence of only a moderate association between the incidence (onset) of back pain and heavy physical work. Interestingly, although the proportion of people involved in heavy work has decreased in industrialized countries, there has been an increase in the number of people with work disability. Heavy physical labor may be a contributory factor in the onset of nonspecific back pain, but it is not a cause in many cases of work disability.

Physical risk factors for occupational back pain include heavy physical labor that entails positions of overextension, repetitive motion, twisting and bending, frequent lifting, awkward postures, and whole body vibration.8

Several recent studies on the specific occupational incidence of LBP provide an interesting overview based on work categories. Military personnel have an increased risk during training and combat deployment; approximately three quarters of duty-related burdens incurred during combat involve low back problems.¹² Low back symptoms are common and persistent among firefighters.¹³ Nurses have reported the highest prevalence of LBP involving musculoskeletal pain problems,¹⁴ as have farmers, who show a greater prevalence of musculoskeletal disorders than do nonfarmer populations, with LBP being the most common.¹⁵

Occupational and Psychological Factors

There is increasing evidence that the work factors leading to chronic disability are more psychosocial than biomechanical, and that they are strongly associated with disability itself and the consequent delay of return to work. The work-related psychosocial factors associated with spinal disorders are a rapid work rate, monotonous work, low job satisfaction, low social support, low decision attitude, and job stress.⁸

Other Issues

Epidemiological studies identify other issues to address in the development of LBP for which there is currently a lack of research evidence, such as (1) the limited diagnostic and prognostic value of medical imaging in nonspecific back pain, (2) the nonpositive but negative effect of bed rest, (3) the nonnegative but positive effect of early return to work, and (4) LBP in children and adolescents. The latter occurs more commonly than previously thought; recent epidemiological studies have shown that the prevalence of nonspecific LBP in childhood is high, matching that of adults by the end of the growth period, and it is becoming a public health concern. A meta-analytic investigation found that the most recent studies showed higher prevalence rates than the oldest studies, and studies with a better methodology exhibited higher lifetime prevalence rates.¹⁶

■ Geographic Variation

The reporting of back pain exhibits some geographic variations, even though there is little epidemiological information about the prevalence of back pain in developing countries.

According to some recent studies, LBP demonstrates a bimodal distribution in the United States, with peaks between 25 and 49 years in men and 65 to 94 years in women; black and Caucasian patients were found to have significantly higher rates of back pain than Asians.¹⁷ In a Canadian population, the prevalence of claims-based recurrent LBP progressively decreased between 2000 and 2007 for younger adults (< 65 years), whereas older adults (≥ 65 years) showed an increase.¹⁸ In a large Latin American study, the estimated prevalence of LBP is 16.7% for the population exposed to few risk factors, up to 65% for the higher risk subgroup,¹⁹ with the most significant risk factors being long periods of time in the sitting position, obesity, pregnancy, smoking, advanced age, lifting and carrying heavy loads, domestic work, sedentary lifestyles, and longer duration of current employment. In Japan, LBP prevalence was highest in people in their 30s to 50s, and it specifically correlated with losing a job, leaving school, or changing jobs; up to 30% reported unchanged or aggravated symptoms and dissatisfaction with treatment.²⁰ An Australian study based on twin analysis (the Australian Twin low BACK pain [AUTBACK] study) has found that heavy domestic physical activity (PA) is associated with an increased probability of LBP, and the combination of heavy domestic and recreational PA might increase the probability of LBP more than heavy domestic or recreational PA alone.21

■ Costs

The CLBP patient population engenders enormous costs for the health care system in terms of medical consultations, diagnostic and therapeutic procedures, hospitalizations, and pharmaceuticals such as analgesics.⁸

Papageorgiou and Rigby²² characterized the back pain-related contact with medical services by applying a one-in-five rule of thumb: one in five of the population experience back pain at any given period of time; of these patients, one in five consult their general practitioner (GP); and one in five of those consulting their GP are referred to a specialist. One in five of those attending outpatient clinics are admitted to the hospital, and one in five of those admitted undergo surgery for any kind of back pain.

The total costs of LBP are thus enormous, and are predominantly caused by disability; only a minority of patients are chronically disabled, but such cases engender most of the costs, because patients with LBP consume close to twice as much health care as the general population.

The economic burden of spinal disorders includes direct, indirect, and intangible costs, as follows:

• Direct costs consist of medical expenditures, such as the costs of prevention, detection, treatment, rehabilitation, and long-term care.
  
• Indirect costs consist of lost work output attributable to a reduced capacity for activity, and result from lost productivity, lost earnings, lost earnings and opportunities for family members, and lost tax revenue. Over 50% of the costs of spinal disorders are related to indirect societal costs.
  
• Intangible costs consist of psychosocial burdens resulting in reduced quality of life, such as job stress, financial stress, family stress, and suffering. Intangible costs are the most difficult to estimate.

■ Treatment

A general treatment concept is to prevent pain from persisting and becoming chronic, by the use of an aggressive, multimodal, preemptive approach for the treatment of acute pain.⁸ Bed rest for longer than 3 days is ill-advised for patients with chronic LBP. Instead, patients should be instructed to stay as active as possible: “Pain does not hurt so much if you have something to do.”

Another important concept is that the pure distinction between organic and psychogenic or functional CLBP can be difficult to make and it is too simplistic, especially when deciding on treatment. Thirty years ago, Menges²³ proposed a three-part classification for CLBP patients consisting of a somatic part, a depressive part, and a “role” part. When the somatic aspect is predominant, role and psychological profile do not present specific problems; generally, the patient demonstrates satisfactory compliance with treatment, which is primarily medical or surgical. When the depressive part is predominant, patients are masking their problems through pain, and the onset of symptoms often corresponds with particular life events; psychological counseling is of primary importance in these patients, and the medical/ surgical approach is secondary pending the resolution of the psychological disturbance. When the “role” aspect is dominant, the other two parts are not absent; there is a long history of interpersonal conflicts, life complications, and clashes with others. Usually after an episode of illness, pain is incorporated into the complex pattern of problems, and the patient’s “sick role” justifies other behavioral components (e.g., sexual problems, a compensatory strategy, etc.). These patients generally have extensive medical records, but medicalization of their pain, especially invasive treatments, could reinforce the patients’ pain behavior and thus are contraindicated; the best management for these patients is behavioral psychotherapy, not surgery.

The seeking of compensation is a significant psychosocial factor in back pain becoming chronic. Social protections and guarantees for employees in Western European welfare systems have promoted “sick behavior” in back pain patients who have low job satisfaction or social problems. Twenty years ago, Blake and Garrett24 discussed the effects of litigation on outcome, comparing two small groups of patients with LBP who were treated with a psychological and physical approach to rehabilitation; significant improvements were achieved in terms of flexibility, muscle endurance, pain reduction, and exercise fitness in both litigants and nonlitigants alike. But, despite reduced impairment and disability, the litigants showed no change in handicap, allowing the authors to speculate that, in the presence of ongoing litigation, patients are less amenable to restoration of function in their daily lives. Therefore, the authors’ findings suggest that litigants fail to translate the gains achieved in impairment and disability measures into improved function.²⁴

Medical forensic issues have increasing impact on the clinical practice of spine specialists, mostly related to the unsatisfactory outcomes of medical and especially surgical procedures performed on CLBP patients. No significant literature is available on this topic, apart from a couple of case reports, but nonetheless there is a general perception that this growing litigation affects the practice of clinical medicine. No specific advice can be given to spine surgeons, except to critically analyze the demands and expectations of CLBP patients, as well as to review their psychosocial situation. It is crucial to assess whether a single-discipline approach is suitable to improve the patients’ condition, or whether a more holistic multidisciplinary biopsychosocial rehabilitation (MBR) approach should be recommended. If so, it is important to explain to patients the reason for this approach and to discourage them from seeking surgery.

■ The Nature of Pain and the Search for an Appropriate Treatment Modality

Often the nature of pain is dependent on the patient’s subjective experiences. Many factors influence the onset of pain and pain-affected behavior, such as cultural factors, the doctor-patient relationship, and the patient’s educational level, socioeconomic status, history, current psychological problems, and employment situation.

By its natural history, acute or subacute LBP appears to be a universal, benign, self-limiting condition. The majority of the LBP population copes with it and does not seek medical treatment, because the symptoms are interpreted as minor nociceptive stimuli, and are managed either by ignoring them or by resting periodically. Whether the person seeks medical treatment seems to depend on the person’s pain perception, care expectation, and cultural patterns of illness behavior.

In contrast, disability due to CLBP, as opposed to LBP, appears to be an epidemic that is not explained by any demonstrable physical disorder or degeneration. For 30 years, CLBP has been known to have enormous worldwide impact on individuals, families, communities, businesses, and society. CLBP is a multidimensional process associated with comorbidities such as anxiety and depression. Recent research using advanced in vivo brain imaging technologies has found increasing insights into the etiology and pathogenesis of chronic pain. Psychometric measures have found significantly higher scores on depression and anxiety scales in the patient population. Voxel-based morphometry (VBM) analysis has demonstrated significant decreases in gray matter density in areas associated with pain processing and modulation (e.g., the dorsolateral prefrontal cortex, the thalamus, and the middle cingulate cortex). Thus, compelling evidence exists that alterations of gray matter architecture in brain regions in CLBP patients should play a major role in pain modulation and control; these results could confirm the hypothesis of a “brain signature” in chronic pain conditions, although the exact mechanisms by which LBP becomes chronic remain unclear.25

The Global Burden of Disease Study 2010 addressed LBP in relation to impairment and activity limitation. Other studies aimed to quantify the burden arising from LBP due to occupational exposure to ergonomic risk factors, and estimated the work-related burden in disability-adjusted life years (DALYs). This analysis was made for each of 21 world regions and 187 countries, separately for 1990 and 2010, using consistent methods. The conclusions were that worldwide, LBP arising from ergonomic exposures at work was estimated to cause 21.7 million DALYs in 2010. The overall population-attributable fraction was 26%, varying considerably with age, sex, and region; 62% of LBP DALYs were in men (mostly of ages 35 to 55 years), and the highest relative risk was in the agricultural sector. There was a 22% increase in overall work-related LBP DALYs between 1990 and 2010 due to population growth.²⁶ There is a need for further information on exposure distributions and relative risks, particularly in developing countries, because LBP arising from ergonomic exposures at work is an important cause of chronic disability.

Treatment of CLBP remains a challenge, as its success is influenced more by the patient’s functioning than by physical problems. No treatment modality or CLBP has demonstrated a clear superiority over other options.⁶ Chronic back pain has multiple etiologies, including neurologic, physiological, psychological, sociocultural, motivational, cognitive, and behavioral factors—all of which should be addressed in a holistic approach.

One treatment approach conceptualizes LBP as a biopsychosocial problem. This approach is supported by the observation that LBP, particularly at the chronic stage, is caused by a combination of factors, and psychological and social factors may play a role in the development and maintenance of pain and disability. Interestingly, several research studies from 25 years ago were already suggesting that a multidisciplinary team approach should be used in managing pain, because there was considerable evidence that MBR could be the most effective method for treating chronic pain. Wider acceptance of the biopsychosocial model and the ineffectiveness of monotherapies have led to increased use of a multidisciplinary approach, which has resulted in promising reports from clinical practice. MBR can be offered in multidisciplinary pain clinics, rehabilitation centers, and outpatient settings. MBR includes elements aimed at improving back-related physical dysfunction as well as addressing psychological issues and targeting social and work-related behaviors. There is some evidence from systematic reviews to suggest that these interventions may have a positive effect on long-term work participation outcomes.²⁷ In the past 10 years, despite the large volume of clinical research focused on identifying the most effective treatments for CLBP, finding the optimal management approach has proved to be elusive.

The Cochrane Collaboration recently conducted a systematic review of LBP studies.²⁷ Previous Cochrane reviews had addressed behavioral treatment for CLBP, physical conditioning programs for improving work outcomes in workers with back pain, and individual patient education for LBP. But these earlier studies are now out of date. The recent review analyzed 41 studies reporting on a total of 6,858 participants. The authors conclude that an MBR intervention for CLBP patients has a more positive effect on pain and disability outcomes than does the standard care or a physical treatment program. It is also likely that MBR will have a beneficial effect on work outcomes compared with physical treatment. However, given the moderate size of these effects and the potentially high cost of an intensive intervention, there is little to gain by using MBR on patients whose condition does not entail a substantial physical and psychosocial impact. Clinical practice guidelines commonly recommend assessment and treatment of physical and psychosocial factors, and then referral to MBR programs only for those patients in whom these factors are present. MBR should not be recommended solely on the basis of chronicity of symptoms.

■ Past, Present, and Future Research Trends

Past

In 1988, in a visionary report, Frymoyer7 suggested that researchers “study degenerative changes in spinal tissues, especially disc and support structures, . . . to distinguish degeneration from injury and disease.” Research studies could include magnetic resonance imaging scans in vivo, genetic linkage with lumbar disk degeneration, disk biology, macromolecules, disk cell phenotypes, markers for disk degeneration, disk nutrition and vascular supply, bioengineering disk models, animal models of disk degeneration, biomechanical studies of kinematics after bony structure excision, instability and facet anatomy, animal models in instability, mathematical models of instability, and load sharing on facet joints.

Present

Traeger et al²⁸ propose a screening tool to predict the risk of chronic LBP in patients presenting with acute LBP. The early identification of at-risk patients will enable clinicians to make informed decisions based on a prognostic profile, and will enable researchers to address a specific clinical phenotype of individuals. Prevention of CLBP must be emphasized. In many patients, an optimal approach at an early stage might prevent pain from becoming chronic, because protracted symptoms promote the development of pain behavior and the so-called pain identity. Recently, Mehling et al²⁹ reported on a 2-year prospective cohort study of risk factors for the progression to chronic pain. The study enrolled 605 patients; 13% had chronic pain at 6 months and 19% at 2 years. A clinical decision rule (CDR) was developed that may help primary care clinicians to classify patients with strictly defined acute LBP into low-, moderate-, and high-risk groups for developing chronic pain. This CDR should have an important future application by general practitioners and by spine specialists.

Future

Future epidemiological research should address the classification of spinal disorders with standardized, reliable, and valid methods, to reach greater agreement on definitions and staging. In addition, using a population-based registries approach, a standard assessment of risk, treatment, and outcomes needs to be developed. Furthermore, a standardized costing methodology is urgently needed, to help estimate the long-term economic consequences of treatment.

■ Conclusions

• Low back pain, and especially its chronic evolution (CLBP), represents a major public health problem in developed countries.
  
• The medico-social aspect of LBP arises from sociocultural factors in modern societies and by the compensation role of welfare systems. These factors could increase the perception of pain and its threshold among patients with LBP, and could promote the adoption of the socially recognized status of “sick” person.
  
• The person at risk of developing a disability should be identified as early as possible in the course of an episode of LBP to prevent the morbidity and high costs associated with chronic disability. The most important factors in predicting disability relate less to physical findings and more to the duration of the current impairment, the history of previous disability, psychosocial factors, occupational requirements, and job satisfaction. It is not surprising, therefore, that these same factors are highly associated with perceived failures of both operative and nonoperative treatment of CLBP.
  
• There is moderate evidence that multidisciplinary treatments such as MBR result in larger improvements in pain and daily function than the standard care or treatments aimed only at physical factors. This may be important for people whose symptoms are not responding to other treatments, but the effects of MBR need to be balanced with their costs in terms of resources and time. Because MBR programs are often intensive and expensive, they are most appropriate for patients with severe or complex problems who have passed a preliminary triage.
  
• Conventional medical treatments and surgical approaches for CLBP have largely failed.
  
• Surgery is a single-discipline treatment, not a multidisciplinary treatment. In a visionary report in 1976, Alf Nachemson2 stated, “For 98% of patients, the present knowledge of the psychologic, social and mechanical stress factors . . . should be utilized for proper counselling, together with attempts at correction with any type of noninvasive modality, according to the preference of the individual physician.” The situation has not changed much in the subsequent 40 years. No noninvasive or minimally invasive treatment has provided evidence of its effectiveness. The risk factors for CLBP disability remain the same.
  
• A single-discipline medical or surgical treatment for CLBP is inappropriate.

■ Chapter Summary

Low back pain, and especially if it is chronic, represents a major public health problem of epidemic proportions in developed countries. The medico-social paradox—more back pain patients even though there are fewer manual labor jobs—is partially explained by sociocultural aspects of modern welfare systems. The compensation role of these systems encourage LBP patients to increase their perception of pain, thus promoting the adoption of the socially recognized status of “sick” person.

Because the patient population suffering from CLBP has been found to be responsible for an enormous proportion of health care costs, the person at risk of chronicity should be identified early in the course of a first episode of LBP, to prevent morbidity and the costs associated with chronic disability.

The factors that predict the development of a disability relate less to physical findings than to the duration of the current back impairment, psychosocial issues, occupational requirements, and job satisfaction. These same factors are associated with the perceived failures of both operative and nonoperative treatment of CLBP.

Conventional medical and surgical treatments of CLBP have demonstrated little success. A holistic approach to CLBP patients is indicated, using preliminary psychosocial triage to identify the nonorganic factors that could influence the perception of back pain as a chronic lifelong problem. There is evidence that multidisciplinary biopsychosocial rehabilitation (MBR) can provide improved results in terms of pain and daily functioning when compared with treatments that address only physical factors. Nevertheless, despite recent advances in diagnosis and treatment, and the evidence provided by epidemiological studies, no definitive treatment has been proposed for LBP, which continues to have a severe impact on individuals, families, and society.

Pearls

♦ Chronic LBP represents a major public health problem that entails enormous direct and indirect costs.

♦ The compensation role of welfare systems promotes the adoption of a status of “sick” person in CLBP patients.

♦ A person at risk of disability should be identified early to prevent morbidity and the costs associated with CLBP disability.

♦ Some evidence exists that multidisciplinary treatments such as MBR can induce improvement in pain and daily function. Due to its high costs in resources and time, it should be adopted only in severe or complex CLBP cases.

Pitfalls

♦ In CLBP patients, conventional and innovative medical or surgical treatments have most often failed.

♦ A single-discipline approach (such as surgery) is not advisable in CLBP treatment.

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