Evidence suggests that low back pain should be managed in primary care, with the first line of treatment being education and advice to keep active at work.

A 2008 survey of all registered physiotherapists in Maharashtra (India) showed that 46 percent of physiotherapists advised patients with low back pain to rest.

63 percent of Indians believe that bed rest is the mainstay of therapy.

A new series of papers in The LANCET highlights the extent to which the condition is wronged, often against best practice treatment guidelines.

According to researchers a prospective study in the period 10th October 2008 of 25251 patients with chronic back pain received in an Indian orthopedic clinic, reported that 100 percent of patients underwent imaging, with 76 % diagnosed with non-specific low back pain and 10 % with spondylosis. According to the Global Burden of Disease study every year, a total of 7.3 million years of productive life is lost in India because of disability from low back pain. Physiotherapist and Assistant Professor Saurabh Sharma, in the Department of Physiotherapy, Kathmandu University of Medical Sciences, told InnoHEALTH magazine in an email interview that he was also aware of practices of low back pain, which is far away from evidence recommendations.” For example, rest, lumbar supports/corsets are prescribed very commonly against the current recommendations.

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Similarly, all patients are prescribed medicines, electrotherapy, taping, and ex-rays. More than half individuals are advised MRI. Similarly, patients are also treated with new treatments that the clinicians claim but have never been tested in clinical trials (research), such as matrix rhythm theory practice in Pune, he said. In reality, a high proportion of patients worldwide are treated in emergency departments, encouraged to rest and stop work, are commonly referred for scans or surgery or prescribed painkillers including opioids, which are discouraged for treating low back pain.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” explains series author Professor Rachelle Buchbinder, Monash University, Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

The series reviews evidence from high-and low-income countries that suggests that many of the mistakes of high-income countries are already well established in low-income and middle-income countries. Rest is frequently recommended in low and middle-income countries, and resources to modify workplaces are scarce.

Low back pain results in 2.6 million emergency visits in the USA each year, with high rates of opioid prescription. A 2009 study found that opioids were prescribed to around 60% of emergency department visits for low back pain in the USA. Additionally, only about half of people with chronic back pain in the USA have been prescribed exercise. In India, studies suggest that bed rest is frequently recommended, and a study in South Africa found that 90% of patients received pain medicine as their only form of treatment.

“In many countries, painkillers that have limited positive effect are routinely prescribed for low back pain, with very little emphasis on interventions that are evidence-based such as exercises. As lower-income countries respond to this rapidly rising cause of disability, it is critical that they avoid the waste that these misguided practices entail,” adds series author Professor Nadine Foster, Keele University, UK.

The Global Burden of Disease study (2017) found that low back pain is the leading cause of disability in almost all high-income countries as well as central Europe, Eastern Europe, North Africa, and the Middle East, and parts of Latin America. Every year, a total of 1 million years of productive life is lost in the UK because of disability from low back pain; 3 million in the USA; and 300,000 in Australia (see GBD for country-specific estimates available).

Low back pain mostly affects adults of working age. Rarely can a specific cause of low back pain be identified so most are termed nonspecific and evidence suggests that psychological and economic factors are important in the persistence of low back pain? Most episodes of low back pain are short-lasting with little or no consequence, but recurrent episodes are common (about one in three people will have a recurrence within 1 year of recovering from a previous episode) and low back pain is increasingly understood as a long-lasting condition.

The authors say that healthcare systems should avoid harmful and useless treatments by only offering treatments in public reimbursement packages if evidence shows that they are safe, efficient and cost-effective. They also highlight the need to address widespread misconceptions in the population and among health professionals about the causes, prognosis, and effectiveness of different treatments for low back pain.

“Millions of people across the world are getting the wrong care for low back pain. Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo,” says series author Prof. Jan Hartvigsen, University of Southern Denmark. “Funders should pay only for high-value care, stop funding ineffective or harmful tests and treatments, and importantly intensify research into prevention, better tests, and better treatments.”

One of my close relatives was suffering from Multiple Myeloma Cancer, which was diagnosed at a super specialty hospital in Delhi and the course of treatment was suggested. Since, I have been in the healthcare arena for about two decades, I was asked to arrange for a second opinion from a reputed government oncologist. While the diagnosis was correct, the course of treatment suggested by this government specialist was quite different creating a bit of apprehension and panic. Since, time was running out and the obvious choice for third opinion was Tata Memorial Centre, I logged on to Navya, which offers an expert decision service in oncology in association with Tata Memorial Centre. By simply uploading some of the medical case reports, Navya offered us evidence based expert decision on the course of treatment, which was in sync with the second opinion offered. The treatment started on time and the relative is doing fine. By click of a button, we could get the advice from one of the best institutions of oncology sitting thousands of miles away.

Welcome to the world of ‘Tech and Disruption’

Healthcare as we know today is undergoing many exciting transformations. For instance, the surgeon may no longer have to depend only on his skills or eyesight or even a computer screen to do complicated surgeries. He can take the help of the da Vinci Surgical System, which os a 3D high definition vision system with tiny wristed instruments that rotate and bend at angles not possible by the human hand. The end result: far greater accuracy and precision in the surgeon’s work. Then there is the exo skeleton, which has now begun helping paralysed people to walk again. And then there are the healthcare aggregators who are bringing various services to patients at the click of a button, and too, to the comfort of their homes. For instance, a person suffering from extreme pain of the lower back and is unable to go to a hospital to take treatment can now book for a physiotherapist to visit his house and give him/her physiotherapy sessions. Sites such as Practo, DocEngage and Lybrate, among others, bring this and many other services to patients at their homes. Similarly, our IVH app is facilitating the whole patient journey and empowering patient from decision making to surgery to recovery process in a transparent and unbiased way.

Internet-of-Things (IOT) is another technology which has begun revolutionising healthcare. Consider the pacemaker. With the IOT, it will be possible to track its functioning and take medical advice at the required time before things go out of hand. And for the exercise conscious ones, they can count the number of steps they walk in a day through an app on the iPhone or other Android phones. This is especially helpful to those who set a target per day. So, the treadmill will not be as sought after, say, in three years from now, as it is now, because that simple app on your phone calculates the number of steps you have walked during the past 24 hours, the and calories shelved.

So, how far can all this go? Consider the Origami robot. This tiny robot placed in a capsule is swallowed by a patient. In the stomach, the capsule dissolves and the Origami robot begins its job. It can remove unwanted items, such as coins or pins from the stomach, and patch up wounds on the stomach lining, all the while being controlled by a technical expert. So, going forward, would it fanciful to think that humans could be imbedded with a chip which would measure all their vital parameters on 24×7-basis and the chip would send out an alert to a medical expert should any of the parameters show signs of going askew? That would be 24×7 medical diagnoses for you by a chip through the IOT!

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Read all the issues of InnoHEALTH magazine:
InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2 
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz 
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw 
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6
InnoHEALTH Volume 2 Issue 4 (October to December 2017) – http://amzn.to/2B2UMLw

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