The Lancet Archives - InnoHEALTH magazine

Low back pain is the leading cause of disability

InnoHEALTH Magazine — Thu, 18 Oct 2018 06:26:22 +0000

Affecting an estimated 540 million people at any one time, but unfortunately, the condition is mistreated against the best-known guidelines. Worldwide, overuse of inappropriate tests and treatments such as imaging, opioids, and surgery means patients are not receiving the right care, and resources are wasted.

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.

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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.

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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.”

The post Low back pain is the leading cause of disability appeared first on InnoHEALTH magazine.

Mohalla Clinics Are Here To Stay

InnoHEALTH Magazine — Tue, 26 Dec 2017 05:29:55 +0000

ALISHA THAPA and SHREYA KUMAR visit the newly launched Mohalla Clinics and report how they contribute to a healthier neighbourhood

Alisha Thapa is working as a community manager in MixORG, New Delhi. She generates content and strategy for brands. Also, she runs campaigns for brands’ engagement and presence on online media channels.

Shreya is an engineering graduate who is working with team InnovatioCuris connecting European Healthcare innovation leaders with the Indian healthcare system and pioneers. She looks forward to pursue her masters in the field of data science. Her interest areas are Indian education, healthcare and transportation.

One of the initiatives of Delhi’s government is about innovations in the healthcare delivery model Mohalla Clinics meaning Neighbourhood Clinics. This is a format of care delivery targeting to improve the access to primary care.
With the launch of the first Mohalla clinic on a trial basis at West Delhi’s Peera Garhi in July 2015, the Delhi government initiated to give an access of basic health facilities to the people of Delhi within walking distance. The first clinic head Dr. Alka Choudhary as the main doctor, an auxiliary nurse midwife, a sister and a technician. The clinic received a positive response from the common people with a recorded visit of 102 patients in just three and-a-half hours.
The government then proposed to maximise these clinics up to one thousand by 2016. However, there are less than 200 Mohalla Clinics operating at present. These clinics are set up with the aim to
1. Ease the burden on over-crowded hospitals.
2. Provide de-addiction counselling, family welfare counselling, lifestyle disease counselling and national programme counselling.
3. Zero cost on check-ups, medicines and tests.
4. Cut down the expenses on travelling and avoid long distance travelling to reach the hospitals by the poor and old-aged people respectively.
5. Immediate recovery from ailments.
At the beginning stage of this initiative, Delhi’s health minister Mr. Satyendra Jain had proposed that Mohalla Clinic could attend 80% of patients’ illnesses (20% with more serious illnesses to visit the hospitals). Mohalla Clinics have been more successful in attending patients than anticipated. the clinics were able to cater 95% of the patients’ illness. Mr. Jain also had spoken about more advancements and digitisation.
Dr Pal while attending a patient at Todapur’s Mohalla Clinic said:
The massive success of this project eventually gained the interests of other states in the country. A Mohalla clinic has been set up in the city of Mumbai in August 2016. Following the footsteps also includes the Karnataka government who announced on September 2016 to open two Mohalla clinics in Karnataka. The Gujarat Health Department decided to replicate the concept in four cities of Gujarat: Ahmedabad, Vadodara, Rajkot and Surat.
The foreign media has equally lauded the initiative. The highly honoured press journals “The Lancet” and “The Washington Post” have mentioned the initiative as a lesson for America.
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The second half of 2016 also marked another technological advancement in the Mohalla Clinics with an upgrade of a Mohalla Clinic in Todapur with a medicine vending machine, replacing the work of a pharmacist. According to the government reports, almost eight lakh patients were treated in five months in the Mohalla Clinics.

The world leaders like Kofi Annan and Gro Harlem Brundtland were highly impressed and congratulated Delhi CM Mr. Arvind Kejriwal. Both the leaders perceived the model of Mohalla Clinic not only as a country’s achievement but also a universal message to uplift the primary health care system.

During the recent visit to a Mohalla Clinic at Todapur, West Delhi by InnoHEALTH (IH) Team, met with Dr Pal, who answered some of the questions of interest.

Q.1. What is a Mohalla Clinic project?

Dr Pal: It is a pilot project with a target of 1000 Mohalla Clinics in the entire city.

Q.2. How do you operate as a doctor of Mohalla Clinic?

Dr Pal: Considering data entry, consultation, examination and prescribing medicines, on an average I spend up to four minutes on a single patient and 60-70 patients during the working period of four hours in a day.

Q.3. How easy it is to access the facilities? Can someone just walk in or they need to show some evidence?

Dr Pal: (While practically demonstrating his procedure with the help of a tab) As you can see, the patient has come for the first time, I register her details like first name, sex, age, marital status, address, mother’s name along with a picture of her clicked and then the consultation part I fill up like symptoms, examination, type of tests, prescription in the tab and finally issue a slip of the prescription.

Q.4. What makes it stand out from other healthcare projects?

Dr Pal: There are three major benefits of this project:
1. The hospitals can improve the quality of services as the load of the patients will be less because their load will be taken by Mohalla Clinics.
2. Only manifested and critical cases are going to the hospitals as patients at their early stages of illness are coming here (Mohalla Clinic) and we are giving all the possible treatments and advices within the clinic.
3. The quality of interaction between me as a doctor and the patient is more comprehensive and we are able to give a service with a personal touch to the community.

Q.5. Who is looking after the expenses of this project?

Dr Pal: It is a government project and the clinic has been set up as rented accommodation. The rent as well as medicines is provided at minimum costs. As a doctor I get INR 30 per patient, my assistant staff and multi-task worker get INR 8 per patient and INR 2 per patient respectively.

Q.6. From the time the project started till present, what is the level of success? And how do you measure the level of success?

Dr Pal: After the completion of one year, I can say the project has been successful. For instance, this area where I am operating consists of a population of approximately ten thousand comprising two thousand families. Surprisingly, almost each and every family has visited this clinic, be it for a minor or major purpose and that is exactly served our purpose. We want more and more people to visit Mohalla Clinics and get the required treatment. And not only the people of this local area but people from places like Noida, Rajasthan, Tamil Nadu, Andhra Pradesh have visited us to learn about this project, which is a proof that other states are also aware, happy and replicating the model.

Q.7. What are the criteria for the selection of doctors for this project?

Dr Pal: Doctors’ selection is done by Directorate of Health Services in the office through walk in interview. One can find the advertisements on newspapers. Doctors can appear along with the required documents and especially the retired doctors are preferred for this project.

Q.8. How often do you refer patients to the hospital for further treatment?

Dr Pal: I hardly refer 1 or 2 patients in a day and rest we take care of ourselves. Patients who are mostly at early stages of the illness come here. For instance, children are prone to disease such as pneumonia and we have been able to detect this disease at the early stage at least in this area and nobody has suffered from this illness. This is how burden of the hospitals is reduced.

Q.9. What are the changes you see in yourself?

Dr Pal: As I’m already a retired person, I’m getting professional satisfaction while working here and I’m able to keep myself fit by continuing to work.

An interaction between IH Team and patient named Pinky at the Mohalla Clinic

IH: What health problems do you have?

Pinky: I’m having high blood pressure problem and Dr Pal has been taking care of me.

IH: How often do you visit this clinic? For how long have you been treated here?

Pinky: I visit this clinic on alternate days and my treatment is going on for last one and a half months here.

IH: How do you find the treatment?

Pinky: Sir is observing my problem really well. My blood pressure test is done very often and he advises me according to the blood pressure chart.

IH: How far do you stay and earlier where were you going for your high blood pressure treatment?

Pinky: My home is quite near. The hospital, where I was previously visiting for the treatment was one hour away from my home, due to which I used to leave from home early in the morning and at times it used to be difficult to manage with my small kid. But now everything has become convenient.

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