Low Back Pain
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LOW-BACK PAIN Frequency, Management and Prevention from an HTA perspective Danish Health Technology Assessment 1999; 1(1) Danish Institute for Health Technology Assessment I T D H A
Transcript of Low Back Pain
L O W - B A C K P A I N
Frequency, Management and Prevention from
an HTA perspective
Danish Health Technology Assessment 1999; 1(1)
Danish Institute forHealth Technology Assessment I TD H A
Low-Back PainFrequency, Management and Prevention from an HTA perspective
Danish Institute forHealth Technology Assessment I TD H A
LOW-BACK PAIN Frequency, Management and Preventionfrom an HTA perspective
Prepared by a working group for Danish Institute for Health Technology Assessment
Published by Danish Institute for Health Technology Assessment
©Danish Institute for Health Technology Assessment
National Board of Health
13, Amaliegade
P.O. Box 2020
1012 Copenhagen, Denmark
ISBN: 87-90765-82-6
ISSN: 1399-0330
This report should be referenced as follows:
Danish Institute for Health Technology Assessment:
Low-Back Pain. Frequency, Management and Prevention from an HTA perspective
Danish Health Technology Assessment 1999; 1(1)
Layout: Peter Dyrvig Grafisk Design
Print: P.J. Schmidt A/S, Vojens
Production: Danish Committee for Health Education
Printed witout solvents, using only natural vegetable colours,on environmentally approved paper.
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Series Title:Danish Health Technology Assessment 1999; 1(1)
Series Editorial Board:Finn Børlum Kristensen, Mogens Hørder, Leiv Bakketeig
Editorial Manager:Peter Bo Poulsen
Editorial Committee:The Scientific Board, Danish Institute for Health Technology Assessment:Mogens Hørder (chairman), Finn Borum, Thomas Gjørup, Torben Jørgensen,Finn Kamper-Jørgensen, Mette Madsen, Frede Olesen, Jes Søgaard, Helle Timm
Foreword
Low-back pain is one of the most frequent reasons for contact withthe health care system. Low-back pain includes different conditions,and treat-ment should, therefore, be individualised. However, it istoday acknowledged that the individual diagnosis and treatment offered to patients with low-back pain, is very varied. This variationis not always and only an expression of the fact that diagnostic andtreatment are adapted to the individual patient.
On this background a number of national and internationalresearch projects have been made using a Health Technology Assess-ment (HTA) approach with the perspective to manifest today’s know-ledge on the problem and the most rational way to handle it.
In 1996, the Health Technology Assessment Committee of theDanish National Board of Health published “The National Strategyfor Health Technology Assessment”. One important strategy elementis:
“Denmark will ensure, that international HTA initiatives are monitoredand the results applied to the Danish National Health Service.”
The background of the present report is to adapt international healthtechnology assessments (HTA) into Danish conditions. The reportconsists of to volumes, where volume 1 is a survey of the extent of theproblem in Denmark, and volume 2 is an evidence-based evaluationof different treatment methods and evidence-based recommendationsfor prevention diagnostics and treatment.
The report was made by a multidisciplinary working group,representing relevant professions in the Health Care sector.
DIHTA finds it of great value, that the multidisciplinary wor-king group was able to agree both on a proposal for clinical guide-lines for diagnosing patients suffering from low-back pain and re-commendations on a number of different treatments and prevention.
It is DIHTA’s hope, that the report will be well received andused by the different professions responsible for treatment as well asby the authorities with the managerial and economic responsibilityfor the health service in Denmark.
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Statens Institut for Medicinsk TeknologivurderingJanuar 1999
Finn Børlum Kristensen
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Contents
DITHA’s summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . i-iv
Members of the panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Health Technology Assessment and sources/references . . . . . . . . . . . . . . . . . . . . . 10
VOLUME 1
1. What is “low-back” pain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Incidence of low-back pain in the historical perspective. . . . . . . . . . . . . . . . . . . . . 16The prevalence of low-back pain in Denmark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Established causes of low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Social and Economic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2. Illness Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3. Risk factors (indicators) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4. Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5. Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33The clinical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Imaging (X-ray, CT and MRI-scans) and spine diagnosis . . . . . . . . . . . . . . . . . . . . . 34Bloodtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6. How do we address the low-back problem from an organisational standpoint? . . . . . . . . . . . . . . . . . . . . . . . . . . 37The present health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Suggestions for the future organisation of low-back pain assessment and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Acute low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Chronic low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
7. Summary and suggested areas of focus. . . . . . . . . . . . . . . . . . . . . . . 43Waiting times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Increased inter-disciplinary co-operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Individual patient information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
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Public information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45X-ray examination of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Hospitalisation/amubulatory treatment/multi-disciplinary teams . . . . . . . . . . . 45Quality control: databases & reference programs . . . . . . . . . . . . . . . . . . . . . . . . . . 46Teaching/research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Increased knowledge of the course of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 47The overall co-ordination of efforts/professional fee schedules . . . . . . . . . . . . . . 48
VOLUME 2
1. The various Danish health professions that treat patients with “low-back pain” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Co-operation between health care providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2. The LPB-group’s analytical method . . . . . . . . . . . . . . . . . . . . . . . . . . 55HTA-blueprint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55The panel’s evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Grading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Costs that are associated with the utilisation of the technology . . . . . . . . . . . . . . 58The panel’s recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Documented treatment effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Active or passive treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Treatment strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Patient information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61The hta-evaluated treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
4. Treatments which can generally be recommended . . . . . . . . . . . . . 63Manual therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Back school/group training/ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Pain relieving medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Exercise therapy according to mckenzie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Exercise therapy/fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5. Treatment methods that can be recommended in certain conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Injections in the muscles, joints, and ligaments and in close approximation to nerves, including acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . 73injections in trigger points, muscles and ligaments. . . . . . . . . . . . . . . . . . . . . . . . . 74Facet and sacroiliac joint injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Epidural injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Massage and heat/cold therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Back surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Spinal stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Stabilising back surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Bed rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
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Transcutaneous nerve stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6. Treatments that cannot be recommended . . . . . . . . . . . . . . . . . . . . 85Corsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Traction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Ultra sound, laser, short-wave therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
7. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Primary prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Secondary/tertiary prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Social assistance programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
8. Economics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Costs of the singular activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Box economic analysis of a course of treatment for “low-back pain” . . . . . . . . . . 93Savings if “recommended treatment courses” are carried out . . . . . . . . . . . . . . . . 94Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97How can these savings be achieved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Concluding comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
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DIHTA’s summary and conclusions
INTRODUCTION
The purpose of this HTA is to adjust international technology assess-ments, already published on diagnosis, treatment and prevention oflow-back pain, into Danish conditions, in order to improve a betterdecision making in the health care system.
METHODS
A broadly composed working group of relevant professionals madethis report as a result of a systematic consensus process based on athorough evaluation of published scientific evidence and clinical ex-pertise.
In the first place the quality of the scientific basis of using eachindividual technology was assessed – carefully guided by equivalentforeign HTA-reports. Based on scientific documentation the state-ments regarding the technology was evaluated on a 4-step scale. Based on estimates a graduation in three degrees was made of the ex-pected economic consumption of resources that the use of each singletechnology would release.
In addition, the group suggested a recommendation/non-recommendation of future use of the individual technology. Explana-tions are linked to each recommendation, so it is clear under whichcircumstances the recommendation is valid.
TECHNOLOGY
A thorough examination carried out at the very first visit is the mostimportant activity in the handling of the low-back pain patient. Themain purpose of the clinical examination is to make a specific diag-nosis and to exclude the existence of serious back diseases. Further-more, it forms the basis for preparation of the most suitable pro-gramme of examination- and treatment for the patient concerned.
The past ten years’ science has clearly shown that a patientactivating treatment strategy, both for the acute and the chronic low-back pain patient is of great importance to ensure a stable effect of thetreat-ment. For a successful treatment result a motivated participa-tion chosen by the patient is important.
ORGANISATION
Interdisciplinary agreements exist among the experts upon the fol-lowing general principles on the organisation of care in the low-backpain area:
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Irrespective of how the patient chooses to contact the healthcare system, it is important that examination and treatment procedu-res are the same.
All treatment should, if possible, take place in the primary sec-tor and in the patient’s own area. This is important in order to avoidunnecessary labelling of the patient and to avoid needless costs for thepatient and/or to the health care system, as for example long trans-ports.
Referral to specialist care or to a specialist centre should gene-rally not occur before other relevant diagnosis/treatment in the pri-mary sector has been tried.
Referral to specialist care or a specialist centre is recommendedat once if alarming symptoms of back disease appear or if the patientdoes not recover within 4 weeks in spite of regular treatment in theprimary sector.
Normally, patients with acute low-back pains are recommen-ded not to consult emergency wards, as most of the emergency wardsare unable to carry out a thorough evaluation of the problem.
In suspicion of bone fracture after trauma the patient is re-commended to contact the emergency services.
Hospitalisation of patients with low-back pain is not recom-mended. Hospitalisation causes unnecessary labelling of the patientand often also a feeling of inactivity and loss of self-determination.
If serious back disease occurs e.g. bad pains, hospitalisationwill often be necessary.
During the treatment course a close co-operation is importantamong the relevant professionals in primary care, for exchange of no-tes from case records (after permission from the patient is obtained),x-rays, treatment results etc.
Individual patient information during the diagnosis-/treatmentefforts should always be a key activity.
The formal and informal routes of referrals should in generalbe kept unchanged.
The organisation of care should enable a division of work,which derives from professions’ – by authorisation – defined businessareas. This prevents or minimises the occurrence of multiple parallelepisodes of care.
It should be ensured that the content of the individual treat-ment course is homogenous, irrespective if the patient consults his orhers general practitioner or chiropractor. Similarity in information
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given to the patient should be ensured, irrespective of the kind of practitioner that evaluates, informs and advises the patient.
ECONOMY
Implementation of improved care programmes, besides causing savings at the budget in the health care system, will also bring about savings of public costs in areas such as transfer payments (sicknessbenefits and pensions). Overall factors in obtaining savings are:
❖ To avoid costly waiting time.❖ To obtain the best possible communication and co-ordination
between professionals involved and with other parties e.g.especially the social authorities.
❖ To avoid that unnecessary or needless diagnosis- and treatmentprocedures are carried out.
DIHTA’S CONCLUSIONS
If the documentation and recommendations of this report are fol-lowed, a range of treatments will definitively disappear from the health care system’s handling of low-back pain, and more effectivepatient episodes of care will represent far a bigger fraction of cases.
In crucial areas implementation of the results of the report should go through interdisciplinary formed reference programmesand clinical guidelines. One obvious subject could be a reference pro-gramme with guidelines for the work out of “correct x-ray proce-dures”of the low back, carried out in co-operation with radiologists,surgeons, chiropractors, reumatologists, general practitioners etc. Inaddition reference programmes describing in which cases blood testsare necessary, should be worked out.
Economic aspects influence practice behaviour, and changes incollective agreements and contracts may cause great effect.
Broad implementation strategies that form a combination ofprinted material, (local, small-group based) problem oriented educa-tion, collegiate influence from opinion leaders, audit-feed back ofactual treatment activity and visit by colleagues to the clinic is bestsuited in order to obtain changes in clinical behaviour. The workinggroup was not asked to deal with future division of work between thecaregivers. There is, however, a need for such a clarification, whichcould be made through discussions and negotiations with public agreement parties such as Sygesikringens Forhandlingsudvalg (TheBoard of Public Health Insurance).
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It is important that the patient early in the treatment course takes an active part by receiving a thorough information. Informa-tion about the problem and treatment is most often repeated severaltimes before the patient gets full insight into the matter. Individual information is recommended and should be based on the individualsituation and need. A strengthened individual information efforttowards the patient – both in the primary-and in the secondary sector– is an important aspect for the strengthening of future efforts. Thecollective agreements’ possibility to promote this information effortshould be analysed critically.
A shared patient record and electronic communication shouldbe developed and tested so that the practitioners can share informa-tion about diagnosis and treatment already carried out.
Common and improved training of physicians, chiropractorsand physiotherapists should be developed so the professions get a more equal approach to the individual patient and a technical lan-guage that is more common than it is today. These courses shouldalso include other relevant professional groups such as teachers ofrelaxation and psychologists. Relevant professional academic envi-ronments should support the training.
Particular courses for social-/rehabilitation staff should be given higher priority than it is in the care today. The newest well-documented professional know how should also form the basis fordecisions about social measures for patients with low-back problems.
The professional groups’ thorough work has revealed a bigneed for a broad scientific effort in the field of clinical science researchand health services research. Methodological competence at high levels is necessary for valid and reliable results. There is, therefore, aneed for supporting academic centres, which are willing to undertakeeducation of scientists and methodology advisers.
The evidence basis for decisions on treatment is regularly chan-ged. Thus, the low-back pain-report must be updated after four yearsat the latest, in order to preserve its relevance.
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Members of the panel
This manuscript is the result of work carried out by a panel whichwas appointed by the Health Technology Assessment Committee ofThe Danish National Board of Health. The manuscript was compi-led by Claus Manniche.
Professor, Chief Physician Claus Manniche MD, (Chairman)*
Economic Affairs Anni Ankjær-Jensen*
Assistant manager Anni Olsen*
Relaxation Therapist Anni FogDanish Relaxation Therapists.
Physiotherapist Kirsten WilliamsDanish Physiotherapy Aassociation
Chief Physician Finn Biering-Sørensen, MDDanish Epidemiologic Society
Peter Kryger-Baggesen, DCDanish Chiropractors Association
Chief Physician Claus Mosdal, MDDanish Society of Neurosurgeons
Hospital Director, Chief Physician Hans Christian Thyregod, MDDanish Society of Orthopaedic Surgery
Chief Physician Erik Martin Jensen, MDDanish Rheumatological Society
Niels-Frederik Pedersen, MDDanish Society of General Medicine
Chief Physician Svend Lings, MDDanish Society for Occupational and Environmental Medicine
Chief Physician Lars Remvig, MDDanish Society for Musculoskeletal Medicine
Professor, Chief Physician Tom Bendix, MDThe Arthritis Association
* Members appointed by the Health Technology Assessment Committee of The DanishNational Board of Health.
Protocol records:Per Bülow, MD
Kim Upperup, of the Center for Health Services Research and Social Politics, University ofOdense, has participated in the production of the Appendix and Appendices A,B, and C.
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Introduction
FOREWORD
In the spring of 1995 the Health Technology Assessment Committeeof The Danish National Board of Health (HTA) appointed a workinggroup which was called the “Low-back pain group” (LBP-group).The task of the LBP-group was to adapt published international HTAreports regarding the diagnosis, treatment and prevention of “low-back pain” to Danish conditions.
Low-back pain has such a high prevalence in the general po-pulation that an episode should almost be classified as a normal oc-currence. Every fifth Dane will experience low-back pain during afourteen-day period. This result in a great utilisation of treatment,sick-leave, and in many cases health related disability pensions.
The LBP-group was comprised of individuals representing thedifferent professional associations that deal with low-back pain andalso included a representative from a musculoskeletal patient associ-ation. Individuals with expertise in administrative and economical af-fairs related to the hospital sector were also included. The scientificsocieties from different medical specialties that are involved with theexamination and treatment of low-back pain each appointed a re-presentative to the LBP-group.
In the fall of 1996 the LBP-group delivered the report entitled“Low-back pain- a delineation of the problem, prevalence and sug-gestions for its management” to the committee, whereupon it waspublished by the National Board of Health. In this manuscript the ini-tial report will be termed Low-back pain Volume 1. This report hasbeen sent out to those responsible for political decisions, health pro-fessional organisations as well as their members in the Danish healthcare sector. The first volume was published in 8000 copies.
In 1997 the Danish Institute for Health Technology Assess-ment was formed, and the responsibility for concluding the work wasplaced here. The LBP-group continued its work until the present report was completed after holding 31 meetings until August 1998.
The LBP-group has carried out its work in an objective man-ner and has demonstrated a willingness to look closely at the entirearea under investigation without political interference. The LBP-
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group has reached agreement on all important issues. There has beensome divergence of opinion as regards a few minor details. The reportis written without the use of too many professionals’ terms, as wasthe case with Low-back Pain, Volume 1. The LBP-group has attemp-ted to write a report that can inspire both politicians and professio-nal decision-makers that are associated with the health care sector.
With the publication of this report, the LBP-group’s work as-signment according to the original commission is completed.
HEALTH TECHNOLOGY ASSESSMENT AND SOURCE MATERIAL
Health Technology Assessment is a thorough, systematic evaluationof the indications and consequences of utilising medical technology.Technology refers to any method used in arriving at a diagnosis, treat-ment or prevention. HTA includes an evaluation of a series of ele-ments which can be classified into the following 4 headings:
Technology (treatment method),The patientOrganisation andEconomic
The LPB-group has at certain times retrieved literature in order to clarify certain areas but has for the most part used the following national and international Consensus -/HTA-reports as the basis forits recommendations.
❖ Back pain- causes, diagnosis and treatment (pages 1-122). Statens Beredning för Utvärdering (SBU), Stockholm 1992, AlfNachemson, report nr. 108, pp 1 – 122. This publication was athorough review of the entire subject including the documenta-tion of different treatments as well as future strategies.
❖ Acute low back problems in adults Agency for Health Care Policyand Research, Public Health Service, Rockville, U.S. 1994. Thisproject included a thorough and systematic review of the availableliterature regarding treatment. The report has been published in auser-friendly fashion and can be used as a reference text. The dif-ferent treatments have been graded according to scientific docu-mentation so that the reasoning behind their recommendations isclear.
❖ Musculo and Skeletal disease in Denmark. Danish Institute for
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Clinical Epidemiology (DICE), 1995. The report is a populationbased survey of the frequency of musculo and skeletal diseases inDenmark. The survey is based on interviews with 4818 danes between September 1990 and May 1991.
❖ Report on Back Pain. The Clinical Standards Advisory Group,London, 1994, pp. 1-47. The epidemiological review is particu-larly thorough.
❖ Consensus report: Low back pain. The Danish Society of Inter-nal Medicine, Ugeskrift for Læger;1996:suppl 4; 1-18. This report is a concise and systematic review of the subject. The em-phasis was on diagnosis and treatment of the most commonacute and chronic low back diseases
❖ Clinical guidelines for the management of acute low-back pain.Royal College of General Practitioners, London 1996, pages 1-35. Organisations contributing to this report included: generalpractitioners, physiotherapists and chiropractors. The report includes practical guidelines based upon the “Report of backpain”, see above.
❖ Conservative treatment of acute and chronic non-specific low-back pain. Van Tulder MW et at. Spine 1997;18:2128-56. This“evidence based” medical evaluation of the most commonly usedtreatment forms for low-back pain was written by a research teamfrom the University of Amsterdam.
If another source has been used this will be referred to in the text. Figures and Tables are always given with references. As far as waspossible reference material representative of the adult Danish popu-lation was used.
11
12
Low-Back Pain
Volume 1
13
14
1What is “low-back pain”?
DEFINITION
In this report, “low-back pain” is defined as tiredness, discomfort, orpain in the low back region, with or without radiating symptoms to theleg or legs. In the remainder of this text these symptoms will be referredto as low-back pain. The definition does not take into considerationeither the duration or the degree of symptoms. Anatomically the lowback is to be considered the area from the lowest rib and downward tothe bottom of the sitting muscles as illustrated in Figure 1.
This definition does not differ markedly from those used in other international HTA-reports. The British report only recognisessymptoms of more than 24 hours duration.
Diagnoses commonly used in clinical practice include: lum-bago, facet syndrome, sciatica, disc herniation, muscle tension, crookedor curved spine, degenerative arthritis, osteoporosis, and so forth.These “diagnoses” may cover a specific condition (osteoporosis ordisc herniation) but for the most they cover a range of symptoms.
The report includes data on people with low-back symptomsof shorter or longer duration. The term acute symptom is to be un-derstood as symptoms lasting less than three months. All symptomslasting more than three months are considered as chronic symptoms.
15
The upper regionof the low-back
The lower regionof the low-back
FIGURE 1
Kilde: Standardised Nordic questionnaires for the analysis of muscoloskeletal symptoms, 1987.
In accordance with the international HTA-reports we do not use theterm sub-acute symptoms in this report. This term is difficult to limitin terms of time and has no particular diagnostic or treatment rele-vance.
INCIDENCE OF LOW-BACK PAIN IN THE HISTORICAL PERSPECTIVE
Discomfort and pain in the low-back was first described on paper in1500 BC by Edwin Smith’s papyrus writings. Prior to the 19th cen-tury the possible relationship between the facet joints, the discs, andnerve irritation and low-back pain was unknown. However, the rela-tionship between fractures and deformities had been known for along time.
In the 20th century it was quickly established that the nervoussystem could be involved in the development of low-back pain andlater on it was widely accepted that low-back pain was possibly cau-sed by an “irritation” of the nervous system. Due to the difficulty inestablishing a physical cause many of the symptoms were consideredto be of an hysterical (psychological) nature. The most commonlyheld belief was that symptoms were a result of an irritated nervoussystem and research focused on this area.
In conjunction with the development of the British railway system (1800-1850) a relationship between heavy work and damageto the back was acknowledged. Prior to this time low-back pain wasnever seen in association to an injured spine. The term “wear and tearof the back” became accepted and individuals were entitled to com-pensation in some instances. Research activity in this field increasedmarkedly but it was still not possible to establish a direct cause andeffect relationship.
During this time, the medical speciality orthopaedic surgerywas developed. As regards low-back pain, bed rest was the most com-monly prescribed treatment. Low-back pain was not treated with bedrest in earlier times, but was considered to be a valid treatment in thisperiod as symptoms appeared to improve in many patients. The useof bed rest was not based upon scientific documentation but ratheron empirical evidence (experience). Current knowledge dictates thatit is both wrong and clinically ineffective to treat almost all low-backailments with bed rest of up to several weeks’ duration.
In 1934 it became clear that the bulging of discal material could result in pressure on the spinal nerves which could in turn result in loss of muscular function and sensory disturbances. This
16
groundbreaking new knowledge regarding the pathoanatomical rela-tionships of spinal structures unfortunately led many physicians to believe that all spinal problems were discal in origin. Many weretherefore of the opinion that surgery would be the answer for mostback ailments. As great advances were being made in anaestheticsand surgical specialities during this period many low-back pain patients underwent surgery; many of them up to several times. Thetendency to overutilise a newly developed treatment modality for aperiod of time has also been seen in other areas of medical science.
The use of long-term bed rest resulted in increased illness be-haviour for low-back patients, which also resulted in physical de-con-ditioning. Many patients became worse off due to bed rest than theywould have been otherwise. Additionally, many patients underwentsurgery in spite of uncertain pathoanatomical findings. These and other factors may have led patients with ordinary low-back pain ona journey ending with severe disabilities.
During the past 30 years much energy has been focused uponreducing workloads as a result of the increased number of low-backpain episodes occurring at the work place.
Many preventative measures have been undertaken in order toprevent repetitive work and heavy lifting at the workplace. In spite ofthese measures the incidence of low-back episodes at the work placecontinues to rise. This development underscores the multi-factorialnature of low-back pain, which includes socio-economic factors aswell as work conditions.
THE PREVALENCE OF LOW-BACK PAIN IN DENMARK
Low-back pain is among the most common painful conditionsin the Danish population. If questioned directly, thirty-five per cent ofthe population will report that they have experienced low-back pain(either short-lived or persistent) during the past year while twenty-one per cent will have experienced back pain during the past fourteendays (Table1). Females report a greater frequency of low-back painthan males however the percentage of disc herniations and long-termlow-back disability is very similar for both genders.
As far as age in concerned there is a weak increase in frequencyfrom ages 16 to 67 whereupon a decrease in frequency takes place forboth genders, but the decrease is not as great for females. In all likel-ihood this is due to osteoporosis which is commonly observed in females of this age group.
17
The British “Report of back pain” documents that the numberof sick-leave days due to low-back pain has increased three-fold du-ring the past fifteen years. The newest data from Denmark also pointto a further increase compared to the data used in this manuscript.
The most frequently reported painful region of the spine is thelow-back (28%), while pain in the upper spine or both the upper andlower regions of the spine are not as common (Table 2). There is nodifference between genders as far as spinal pain localisation is con-cerned (Table 2.)
ESTABLISHED CAUSES OF LOW-BACK PAIN
In this section “causes” should be considered as objective fin-dings such as; x-ray findings and blood tests which may explain thesymptoms. Factors such as heavy lifting or repetitive work (externalfactors) are not considered even though they may influence low-backsymptom development.
We are aware of a wide variety of diseases/conditions, whichcan contribute to or cause low-back pain but even after a thoroughexamination it is not possible to make an accurate diagnosis in 70-80% of patients. In the remaining 20-30% a diagnosis can be madeon the basis of objective findings which cannot be found in healthy
18
TABLE 1Percentage of males and females with various low-back problems in different age groups
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Percent with:
- Back pain within the past year *) 34 42 40 24 38 41 42 45 37 42 40
- Low-back painduring the past year 27 36 35 22 33 34 36 41 34 37 35
- Daily back pain during the past year *) 2 6 11 11 8 6 8 15 20 12 10
- Back pain during the past 14 days *) 12 19 21 16 18 18 21 26 27 23 21
- Disc herniation during the past year - 1 3 1 2 - 1 3 3 2 2
- Other back diseases during the past year 9 15 19 9 15 11 11 21 16 15 15
- Long-term disease 3 7 11 7 8 4 5 15 9 8 8
# of interviewed people 378 923 693 311 2305 388 947 738 440 2513 4818*) Back pain in this row is to be considered as both upper and/or lower back pain but not neck pain. Ref. DIKE 1991.
individuals. There is however an element of uncertainty with this lat-ter group as well. It has been demonstrated scientifically (CT-scan-ning) for example, that between 25% and 75% of healthy individu-als have positive findings suggestive of disc herniations. Degenerativechanges in the spine as seen on plain x-rays should be considered asa part of the natural ageing process. Approximately fifty per cent ofall people over fifty years of age have degenerative changes but the incidence of low-back pain is equivalent in people either with orwithout spinal degeneration.
SOCIAL AND ECONOMIC FACTORS
There are no specific data regarding the influence of social and eco-nomic factors and low-back pain for the individual but musculoske-letal disease is the most common cause of decreased daily activity,sick-leave and disability pensions (Table 3).
19
TABLE 2The percentage of males and females with back pain during the previous year
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Pain only in the upper region of the back 8 6 4 2 5 7 7 5 3 6 5
Pain only in the lower region of the back 23 33 30 17 28 28 29 30 24 28 28
Pain in both the upper and lower regions of the spine 4 6 6 4 5 9 6 10 9 8 7
No spinal pain 66 55 61 77 61 57 58 14 63 58 59Back pain in this Table is either pain in the lower and/or upper back but not the neck. Ref. DIKE 1991.
TABLE 3The relative contributions (percentages) of various diseases that result in activity decreases, change of workor loss of work, and disability pensions
Activity - long-term- - short-term- job change/ -job change- -job loss health relatedlimitations loss disability pension
Musculoskeletal disease 38 47 21 45 47 43 33
Heart/vascular disease 6 9 1 9 5 13 14
Nervous system disease 5 6 4 6 5 8 11
Respiratory disease 20 9 3 9 5 5 5 5
Injuries 10 7 14 8 10 5 6
Psychological illness 2 2 1 7 6 8 8
Other diseases 19 19 21 20 22 7 22The numbers are given as percentages of all disease groups. Back disease represents approximately 50% of all musculoskeletal disease. Ref. DIKE 1991.
The lower back is the most frequent problem area of the entiremusculoskeletal system, and as such we can use the data from the en-tire group. Similar data can be found from other Western countrieswhich we normally compare ourselves.
In Denmark, more than 120,000 hospital days as a result ofdisc and other vertebral lesions were documented (Table 4). In addi-tion to this, a large patient group exists with more diffuse symptomssuch as osteoporosis, or referred pain from other organs. Accordingto the Ministry of Health’s figures from 1993 the total number of hospital days due to somatic disease in Denmark was 7.5 million. Thegroup including spinal disease, disc herniation, osteoarthritis as wellas other related illnesses was calculated to be 330,000 days per year.This number equals the yearly hospital day capacity of one of the lar-gest hospitals in Denmark.
The number of hospital days used for back illness has remainedfairly constant from 1983 to 1993 in spite of the fact that it has beenshown that hospitalisation for most back conditions has been shownto be unnecessary or even contributory regarding the promotion of illness behaviour. At present there are no separate numbers as regardscosts regarding low-back pain patients as opposed to the overallgroup of musculoskeltal patients. The possibility of arriving at precisepublic health costs associated with low-back disease is made difficultby the fact that certain disease costs are not classified singularly. Forexample, services provided in the primary health care sector are notregistered systematically (how many patients, what type of treatment,which diagnoses?). It is also difficult to calculate the exact public costsassociated with sick-leave and disability pensions directly related tolow-back disease alone, because many patients are unable to workfor differing periods of time due to several competing diseases which
20
TABEL 4Number of hospitalisation days for chosen diagnoses in Denmark 1994.Diagnosis Discharged # of days at hospital Discharged # of days at hospital
÷ operation ÷ operation + operation + operation
Lumbar disc herniation 4778 43566 2880 26828
Degeneration of discs orbones in the low-back 1682 16938 498 5709
Low-back pain without signs of disc herniation 2696 25319Reference: National patient registry, Ministry of Health 1995
21
TABL
E 5
Soci
al co
sts f
or 1
3 di
seas
es in
Den
mar
k ca
lcul
ated
acc
ordi
ng to
the
cost
-of –
illn
ess m
etho
d.Fi
gure
s are
pre
sent
ed a
s mill
ions
of D
KK
(199
2 pr
ice
inde
x).
Dire
ct co
sts1)
Indi
rect
cost
s2)Co
sts
Dise
ase
Hosp
ital
Prim
ary3)
Tota
ls%
4)r%
5)Si
ck-le
aver
6)Pe
nsio
n7)De
ath
Tota
ls%
4)r%
5)To
tal
s%4)
Ra
nk
Mus
culo
skel
etal
dise
ase
1.84
81.
295
3.14
38,
414
,85.
127
12.8
9111
218
.130
17,7
85,2
21.2
7315
,22
Canc
er3.
234
485
3.71
99,
923
,195
33.
320
8.08
812
.361
12,0
76,9
16.0
8011
,54
Resp
irato
ry d
iseas
e1.
617
1.14
52.
762
7,4
39,5
847
2.31
01.
079
4.23
64,
160
,56.
998
5,0
7
Inju
ries/
accid
ents
2.77
257
83.
350
9,0
27,1
4.06
72.
339
2.61
59.
021
8,8
72,9
12.3
718,
85
Dise
ases
of t
he d
iges
tive t
ract
1.84
868
02.
528
6,8
36,7
1.90
790
91.
538
4.35
44,
263
,36.
882
4,9
8
Nutri
tiona
l and
met
abol
ic di
seas
es92
440
01.
324
3,5
40,7
01.
265
668
1.93
31,
959
,33.
257
2,3
10
Psyc
hiat
ric d
iseas
e3.
446
736
4.18
211
,214
,42.
224
22.1
2254
024
.886
24,2
85,6
29.0
6820
,71
Dise
ases
of t
he n
ervo
us sy
stem
,eye
s,ea
rs92
497
81.
902
5,1
28,0
1.14
43.
249
503
4.89
64,
872
,06,
798
4,9
9
Dise
ases
of t
he u
rinar
y tra
ct an
d re
prod
uctiv
e org
ans
924
605
1.52
94,
160
,363
428
191
1.00
61,
039
,72.
535
1,8
12
Infe
ctio
us d
iseas
es69
324
293
52,
538
,321
286
043
21.
504
1,5
61,7
2.43
91,
713
Hear
t and
vasc
ular
dise
ase
4.62
01.
305
5.92
515
,833
,21.
843
4.45
75.
595
11.8
9511
,666
.817
.820
12,7
3
Dise
ases
rela
ted
to p
regn
ancy
1.61
755
02.
167
5.8
81,5
4.87
33
493
0,5
18,5
2.66
01,
911
Othe
r dise
ases
8)2.
078
1.86
639
4410
,533
.11.
697
1.10
55.
169
7.97
17,
866
,911
.915
8,5
6
Tota
l26
.545
10.8
6537
.410
100
26,7
21.1
4255
.111
26.4
3310
2.68
610
073
,314
0.09
610
01)
BTr
eatm
ent c
osts
incl
uded
onl
y re
sour
ces u
sed
in th
e he
alth
care
sect
or a
s def
ined
in D
enm
ark.
In o
ther
wor
ds,c
osts
rela
ted
to h
andi
cap
dwel
lings
and
oth
er so
cial
cost
s are
not
incl
uded
2)
The
pre
sent
val
ue o
f pro
duct
ion
loss
,dis
coun
ted
by a
fact
or o
f 4%
.3)
Inc
lude
s onl
y ge
nera
l pra
ctit
ione
rs,s
peci
alis
t pra
ctic
es,p
hysi
othe
rape
utic
trea
tmen
t,ch
iropr
acti
c,an
d th
e us
age
of m
edic
ine
outs
ide
of th
e ho
spit
al se
ctor
.Cos
ts in
clud
e bo
th p
ublic
hea
lth
insu
ranc
e co
sts
as w
ell a
s the
dire
ct co
sts p
aid
by th
e in
divi
dual
pat
ient
s.Th
e di
agno
stic
clas
sific
atio
n is
the
one
used
in 1
989
4) C
olum
n pe
rcen
tage
s,in
oth
er w
ords
,dis
ease
spec
ific c
osts
in re
lati
on to
tota
l col
umn
cost
s.5)
Row
per
cent
ages
,in
othe
r wor
ds,t
he d
isea
se sp
ecifi
c dis
trib
utio
n of
cost
s of b
oth
dire
ct a
nd in
dire
ct co
sts
6) O
f non
-per
man
ent c
hara
cter
,the
dis
ease
dis
trib
utio
n is
from
198
17)
Perm
anen
tly
redu
ced
abili
ty to
wor
k or
tota
l los
s of a
bilit
y to
wor
k;di
seas
e di
stri
buti
on is
the
aver
age
of 1
989-
91.
8) I
nclu
des p
rodu
ctio
n co
sts o
f 2.3
bill
ion
Dani
sh D
KK re
late
d to
suic
ide,
whi
ch is
not
incl
uded
und
er in
jurie
s/ac
cide
nts o
r und
er p
sych
iatr
ic d
isea
ses.
Sour
ce:N
astr
a Re
com
men
dati
ons n
r.12
84,1
995.
may be present simultaneously. In our group we concluded that it wasimpossible to acquire more precise data without initiating severalcostly analyses.
Indirect costs can be evaluated by using data from the wholedisease group “musculoskeletal diseases.” Table 5 shows both the direct and indirect costs of 13 chosen disease groups. Only psychia-tric diseases are more costly to society than muscoloskeletal disease.The numbers cover the entire musculoskeletal disease area and as pre-viously stated low-back disease contribute approximately 50% of thecosts of this disease group. The yearly costs to society are thereforeroughly 10 billion DKK. Note that the direct costs of this group areless than several of the other groups. However, the large indirect costsresult in the great total costs related to this disease group. We con-clude that considerable savings will mainly come from reducing theindirect costs.
22
2Illness Behaviour
Illness behaviour includes all forms of reactions resulting from signsand symptoms of a disease. Examples include conscious inactivity,self-treatment, and seeking help from health professionals as well asfrom friends and family.
Many individuals (approximately 30%) suffering from mus-culoskeletal symptoms do not alter their activities of daily living nordo they seek help in the form of treatment (Table 6, page 24). Thereis no data in the DIKE report which deals specifically with low-backpain, however, it is unlikely that this group differs from individualssuffering from other forms of musculoskeltal pain.
A large group attempt to tackle their low-back pain problemby altering work patterns, changing the ergonomics of their work-stations, or by participating in preventative fitness training programs(Figure 2, page 25).
Individuals suffering from severe pain or disability will natu-rally seek help from health professionals at greater rates than others.(Table 7 page 24). There is therefore, a clear relationship between painintensity and treatment although approximately 68% of individualssuffering from severe pain do not seek treatment even though 88% ofthese individuals do not believe that their symptoms will subside.
Twenty-three per cent of individuals suffering from low-backpain that seek professional help will initially contact their general pra-ctitioner. A group (12%) will seek help from a chiropractor either separately or at the same time that they contact their general prac-titioner. Slightly less than fifty per cent will be referred to a physio-therapist (9% of all patients seeking help). Only a small percentagewill be examined and treated by a specialist in rheumatology or at ahospital. The vast majority of treatment is provided in the primaryhealth care sector by general practitioners, physiotherapists or chiropractors (Table 8, page 24).
Thirty-seven per cent of individuals suffering from low-backpain will seek treatment within a year (DIKE 1995). The percentageof individuals that seek care due to low-back pain related functionaldisabilities are greater than those suffering from other diseases of the
23
24
TABLE 7Percentage of differing illness behaviour among people with different types of musculoskeletal symptoms given in percentages (%).
With severe With reduced Are not capable Have symptoms Tired due to Have had Do not expect pain activity levels of doing what from several symptoms symptoms that their
what they areas of for a longer symptoms would like to the body period of time will resolve
Has done nothing 14 20 24 25 21 30 32
Self-treatment only 54 49 52 57 55 56 56
Sought treatment (and eventually did something themselves) 33 31 24 18 24 14 12
In total 100 100 100 100 100 100 100
Source DIKE 1991
TABLE 8The number of consultations with health professionals during the past year and the number of treatmentsfrom all individuals suffering from low-back pain.
Percentage with Average number Number ofcontact (%) of contacts treatments*
general practitioner 23 3,5 417.000
Physiatrist or rheumatologist in private practice 4 6,5 135.000
Doctor at a hospital department 4 4,0 83.000
Physiotherapist at a hospital 4 8,4 174.000
Physiotherapist in private practice 9 11,7 545.000
Chiropractor 12 6.5 404.000
Total number of treatments 1.758.000The same person can have received treatment from several health professionals.*The number of treatments is derived from the fact that there are 4 million Danes over the age of 16, of which 35% have had trouble with back pain during the past year and 37% of whom have sought treatment.Source DIKE 1991
TABLE 6Illness behaviour among males and females in different age groups suffering from musculoskeletal symptoms during the past 14 days given in percentages (%)
Males Females
16-24 25-44 45-66 67+ Total 16-24 25-44 45-66 67+ Total M+F
Has done nothing 42 34 33 42 36 29 21 22 35 25 30
Self-treatment only 44 50 51 47 49 60 62 62 47 58 55
Self-treatment and sought professional care 9 12 15 7 12 8 14 13 13 13 12
Only sought treatment 4 3 1 4 3 3 2 3 6 3 3
In total 100 100 100 100 100 100 100 100 100 100Source DIKE 1991
musculoskeletal system (10-20%). This can be interpreted to meanthat low-back pain related symptomatology is perceived as requiringmore treatment than other diseases of the musculoskeletal system.
� 35% of the Danish population report having low-back pain during the past year
� 37% of individuals with low-back pain seek treatment� The number of sick-leave days has been increasing the past 20-30 years� At the present time there is no scientific evidence that low-back trouble
has changed character. The increase in the number of back complaintsmust therefore be a result of changed work or psychosocial aspects
� Low-back pain results in a total cost to society of over 10 billion DKK
25
0% 10% 20% 30% 40% 50%
Advice from family and friends
Avoid certain work position
Rested more
Hot packs
Alternative (natural) medicines
Medicines
Fitness centre
Usual physical activity
Increased physical activity
Gymnastics
FIGURE 2The percentage who attempt different things in order to reduce symptoms due to musculoskeletal trouble
Source DIKE 1995
3Risk factors (indicators)
Risk factors relates to factors that have a probable influence regardingthe development of as well as the course of low-back pain, but shouldnot be confused with a cause and effect relationship which requires secure knowledge regarding a direct relationship between an injury resulting in low-back pain. The scientific literature in this area is ratherunclear both regarding the clear definition of the involved terms aswell as the statistics employed. For example, many risk factors havenot been examined as far as their relationship to one another is con-cerned. Utilising the term factors can therefore result in misunderstan-dings while the term indicators (to be a sign of, to represent, or to reflect) more accurately describes our concerns. Generally the term factors is more commonly used in the literature and we will followsuite in this report.
Our knowledge regarding possible risk factors has been derivedfrom large population studies where a statistical correlation betweenrisk factors and low-back pain in the studied population has beenfrequently demonstrated. The relationships are very complex due tothe fact that many factors have to be evaluated at the same time. Ad-ditionally, unknown factors may play a role in the development oflow-back pain as may factors that have not been recorded.
Results from research may present conflicting conclusions.However, for a number of factors there is solid documentation of a relationship between exposure and the general development of low-back pain. The degree and duration of exposure will influence both thedevelopment and the course of low-back pain.
Traditionally, risk factors are divided into individual and exter-nal groups. Furthermore, there are factors, which contribute to the de-velopment of chronicity. Individual factors are related to the person inquestion, while external factors most often relate to work or social fac-tors. However, a clear separation of these factors is not always possi-ble. Similarly, risk factors regarding the development of acute andchronic low-back pain oftentimes overlap. This can be seen in Figure3, where there is no clear separation between the different risk factors.
A series of different factors are important as regards the frequ-ency as well as the duration of low-back pain for the individual per-
26
son. Oftentimes, several risk factors (both known and unknown)acting simultaneously will affect the course of low-back pain and itcan be impossible to determine which of the factors is the most im-portant.
In Figure 3 a series of risk factors are presented under the hea-ding “proven”. These factors are regarded by most experts as beingmost frequently involved in the development of low-back pain, butthey should not be regarded as obligatory. At the present time it is notpossible to propose a list, ranking the most important factors.
We cannot for example conclude that “heavy lifting” contri-butes more frequently to the development of low-back pain than either“psychological stress or low social status”.
In the future, it will be of great importance to study risk factorsresponsible for the development of chronic low-back pain because thisoftentimes results in patients being sick-listed for several years, recei-ving endless amounts of treatment, and ending with permanent dis-ability pensions. Risk factors of importance as far as this issue is con-cerned include: long-term sick-listing, exaggerated illness behaviour,stress or depression, low levels of job satisfaction, smoking, and on-going litigation/pension procedures.
During the course of the last twenty years, decision makers aswell as the population at large have been led to believe that back-painis most often due to many years of heavy lifting or inappropriate sea-ting postures. This has logically resulted in preventive measures beingundertaken at the workplace aimed at reducing the pace of work aswell as the number of heavy lifts. During this period, the number ofpeople suffering from low-back pain has unfortunately increased mar-kedly. This is in all likelihood due to the fact that only some of the cases of back-pain are mainly work-related. A great number of low-back complaints are a result of other social as well as individual factors.
Among the HTA participants there is agreement that “indivi-dual factors” are at least as important regarding the development oflow-back pain as are the external factors. It is essential that in futurepreventive activities, all known risk factors be addressed (both indivi-dual and external).
� Individual risk factors are at least as important regarding the develop-ment of low-back pain as are external factors
� Future preventive measures must address both individual and externalfactors
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Individual risk factors External risk factors
Risk factors for thedevelopment of chronic
low-back pain
Age (1)
Low social class
Psychological stress (2)
Reduced enduranceof the spinal muscles
Depression
Long termsick-listing
Clinical impressionof disc herniation
Exaggerated illnessbehaviour
Work-related/compensation-/pension ongoing
Poor jobsatisfaction Driving > 2 hours
Highly repetitive work
Many heavy lifts
Genetic disposition
Obesity
Poor physical health
Poor general health
Personal problems (3)
Alcohol abuse
Smoking
Radiating painto the leg
Sedentary work
Many aggrevating twisting
Previous back pain
FIGURE 3Possible and proven risk factors regarding the development of low-back painPossible will be presented in normal font, while proven will be given in bold type.
1) Greatest risk for males aged 40-50. Great risk for females over age 60.2) Proven as regards chronic back-pain but should be considered a possible risk factor as regards acute back pain.3) Alcohol, marital or economic difficulties.
4Diagnostics
DIAGNOSES
During the years many different diagnostic classification systems of low-back pain have been devised in order to arrive at a likely diagnosis. Emphasis has either been placed upon the anatomiclocalisation, causes or symptoms. None of these attempts at classi-fying patients has been comprehensive enough to cover the wide spec-trum of low-back pain.
It has become accepted in professional circles that it is im-possible to make a specific diagnosis in approximately 70-80% of cases regardless of how thorough the examination procedures havebeen. Due to a lack of solid biological causes the terms “non-specificback pain” or “simple back pain” have become widely used.
Non-specific low-back pain is divided into the following classifications, which are based upon patient symptom description.These divisions have been shown to be of value regarding the healthprofessionals’ need of further examinations and treatment strategydesign.
� Acute low-back pain� Chronic low-back pain� Acute low-back pain with radiating symptoms to the lower extremity � Chronic low-back pain with radiating symptoms to the lower extremity
Certain diagnoses can however be based upon a pathoanatomical basis. This of course depends upon a clear correlation between ana-tomical findings and patient symptoms. This is possible in approxi-mately 30% of low-back pain patients.
Degenerative low-back conditions. This term covers a variety of con-ditions including spondylosis, disc degeneration/herniation, spondy-loarthrosis, and is generally considered to imply degeneration takingplace somewhere in the spine. Spinal degeneration is a natural phe-nomenon, which can commence at different periods of an indivi-dual’s life. Severe degeneration of the spine can result in either con-stant or periodic pain. Our present knowledge regarding the biologi-
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cal mechanisms of spinal degeneration and their relation to spinalsymptoms is very sparse.
A OVERVIEW OF DIAGNOSES IN WHICH THERE IS A CORRELATION BETWEEN OBSER-VED FINDINGS AND SYMPTOMS
Degenerative Conditions: Other:Spondylosis/disc degeneration Scheuermann’s Disease
at several levelsSpondyloarthrosis DiscitisDisc herniation Infectious spondylitisSpinal stenosis Osteoporosis
Spinal tumors
Spondylosis/disc degeneration (osteoarthritis of the bones or discs)can be identified with the following x-ray findings: Reduced discal height, sclerosis of vertebral bodies or calcification of the discs. X-rayfindings usually correlate poorly with symptoms. Even severe dege-nerative findings do not necessarily result in symptoms.
Spondyloarthrosis (degeneration of the true joints of the spine) refer todegenerative changes of the facet joints between the vertebra. Due tothe anatomy of the region there is a poor correlation between joint degeneration and pain localisation. It has been shown experimen-tally, for example, that facet joint irritation can result in gluteal pain.Spondyloarthosis usually develops as a result of reduced disc height.
Disc herniation is commonly associated with low-back pain in thegeneral population. Symptoms result from the nucleus of the discpressing on the spinal nerves and/or resulting in a chemical irritationof the nerves due to tears in the discal fibbers. These nerves are a partof the sciatic nerve. Symptoms can vary according to the level of thedisc herniation, however radiating pain to the leg and weakness of thefoot are frequently observed. Disc herniations can also be found in individuals that have no symptoms at all. In spite of the oftentimesdramatic course of events in the acute phase of a disc herniation, thelong-term prognosis is most often favourable. Only one out of fourpatients require surgery.
Spinal stenosis refers to a condition with reduced space in the spinalcanal due to degenerative changes. In conditions, which result in
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symptoms due to pressure on the nerves, the most usual symptomsare pain and decreased strength in the legs. Symptoms usually develop after a period of time.
Scheuermann’s disease occurs in the growth zones of the vertebra.This results in an alteration of the shape of the bodies of the vertebrafrom the classic block-like form to a wedge form. This process takesplace during puberty and is more commonly found in males. This disease is most commonly seen in the thoracic spine (chest) althoughit can also be found in the low-back. Symptoms resulting from a thoracic Scheuermann are rare whereas symptoms from the low-backare more frequently (but not always) observed.
Arcolysis is a defect in the part of the bone that connects the facet joint to the vertebral body. This is a common finding in 5% of theadult Danish population and can be found in 35% of the Eskimo population. This condition does not necessarily result in pain. If how-ever, a spondylolisthesis results in a vertebra slipping forwardly onthe vertebra below symptoms may develop. This condition can alsobe found as a result of degeneration of the disc or facet joints.
Scoliosis is a condition with unusual curves of the spine in the sideplane which can be a result of unequal leg lengths (non-structural) inas much as 20-30% of the population. However, scoliosis may alsobe a result of changes in the vertebra, muscles and connective tissues.In younger people scoliosis is due to a developmental defect while inolder individuals it is oftentimes seen in association with degenerativechanges in the spine.
Discitis is an inflammatory condition (sometimes bacterial) in the discs of the spine. It most frequently results after surgery (1-2%).
Infectious spondylitis is a bacterial inflammation localised to one ormore vertebrae. The bacteria usually spreads through the blood. Thisdisease is usually found in individuals with weakened immune systems, among the elderly, in individuals with systemic disease (dia-betes), or in drug abusers. Initial symptoms include fever and backpain. It is characterised by extreme tenderness to pressure of the adjoining vertebrae.
Sacroiliitis/Ankylosing spondylorarthritis is an inflammatory pro-
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cess in the joints of the pelvis and the sacrum as well as in the jointsof the spine. This process can be found in conjunction with other arthrotides or independently.
Osteoporosis refers to a lack of calcium in the bones resulting inchanges in structure which may result in fractures after seeminglyminor trauma. Osteoporosis is most frequently seen in elderly fema-les due to decreased estrogen production after menopause. This re-sults in a negative balance in the process of during which bone tissueis renewed and torn down.
Spinal tumors include both benign and cancerous tumors. Primaryspinal tumors are quite rare and most are a result of metastasisingcancer from either the lungs, breasts, or bladder. Most patients arefrom 50-60 years of age but tumors can be found in all age groups.Symptoms include pain, which is oftentimes worst at night, weaknessand sensibility changes in the legs. The course can be either slow orquick depending on the localisation of the tumor.
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5Diagnostic procedures
For most patients suffering from low-back pain a thorough interviewand clinical examination will suffice. These procedures will reducethe likelihood of there being an underlying pathology, which is causing the low-back pain in either acute or chronic low-back pain.The interview includes a thorough round of questions regarding howand when the pain developed as well as the course of the symptoms.Information regarding previous episodes of low-back pain is also relevant to discuss. A comprehensive review of potential risk factorsregarding the development of chronic low-back pain is also of extreme importance.
The interview is followed by the clinical examination. The pri-mary purpose of the clinical examination is to attempt to make a spe-cific diagnosis as well as to make sure that there is no serious illnesspresent, which may require further examination. A thorough exami-nation is also necessary in order to determine the most appropriatetreatment strategy for the patient and to avoid unnecessary repetitiveexaminative procedures.
In the opinion of the HTA group, the initial examination is thesingularly most important activity as regards the management of thelow-back patient. If properly carried out one can evaluate the magni-tude of the patients problem, determine if additional examinationsare necessary and initiate treatment. It may also be possible to weighthe risk of chronic symptom development and to initiate preventivemeasures.
The clinical examination should include a relevant number ofthe diagnostic tests, which are described below. A particular problemis the differing attitudes regarding the validity and interpretation ofcertain clinical tests both intra- and interprofessionally. This often-times results in patients receiving contradictory information.
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THE CLINICAL EXAMINATION
1. Postural anomalies (curved spines)2. Spinal motion3. 3. Gait analysis4. Pain tests (tenderness of the spine)5. Lasegue’s test (straight leg raising)6. Neurological tests (sensibility, reflexes, strength)7. Rectal examination8. Para-clinical tests (x-ray, blood)
IMAGING (X-RAY, CT AND MRI-SCANS) AND SPINE DIAGNOSIS
Traditionally, a x-ray of the spine is one of the first examinations un-dertaken in low-back pain patients. However, this examination forthe most part does not provide any meaningful information for themajority of patients, as x-ray findings generally correlate poorly tosymptomathology. Additionally, x-ray findings rarely provide usefulinformation regarding the course of the problem such as the risk ofdeveloping chronic symptoms.
� Only in circumstances where the health professional suspects the pre-sence of infection or other inflammatory conditions, fractures or cancerwill x-rays provide information of importance regarding further examina-tive procedures and treatment.
It is the opinion of the HTA group that x-rays should only be gene-rally entertained if the low-back pain has been present for at leastfour weeks. Ordering x-rays earlier in the course of events is not ethically or economically acceptable. Only in circumstances wherethe health professional is led to believe that other diseases may be pre-sent can the above conclusions be circumvented.
One should attempt to secure previously taken x-rays (1-2years old) at the initial consultation and to make sure that patientshave their x-rays with them if referred to other health professionalsin order to prevent unnecessary x-ray exposures and delays. The rea-son that x-ray examinations are oftentimes repeated is that they can-not be retrieved quickly enough or due to poor quality. The HTAgroup strongly recommends that guidelines for “proper x-ray proce-dures” for low-back patients be prepared. This can be done throughco-operation between radiologists, surgeons, chiropractors, rheuma-tologists and so forth. It is also necessary to evaluate the best method
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of storing x-rays so that health professionals can retrieve them asquickly as possible so that treatment strategies are not delayed.
More advanced imaging such as CT and MRI -scans (with orwithout contrast fluids) are rarely indicated in acute low-back painfor the same reasons as mentioned above. Scanning procedures should only be entertained if patients are experiencing functionallydisabling symptoms such as severe back or leg pain for more thanmonth and/or if surgical is likely.
The x-ray procedure involving the injection of contrast fluidsin the spinal canal (myelography) is still commonly used in hospitalseven though the information provided is similar to that of other pro-cedures. Myelography is not used as frequently as in previous timesdue to the risk of pain development, severe headache (days to weeks)and the slight risk of infection. The HTA groups suggest, in accor-dance with international trends, that less invasive procedures such asCT or MRI scans be used as the standard procedure in the investiga-tion of disc herniations as opposed to myelography. In cases wherethere is a suspicion of spinal stenosis (narrowing of the spinal canal)myelography may be the procedure of choice.
The costs of these different procedures varies from place toplace, with x-rays ranging from 375-1000 DKK myelography 2500DKK, Ct-scans 4000 DKK and MRI-scans 7000 DKK.
These figures do not include costs associated with treatmentand eventual side effects.
Considerable amounts can be saved by avoiding unnecessaryexaminations or repeated examinations and if these procedures are(as far as is possible) initiated only if surgery is being entertained.
BLOOD TESTS
In the vast majority of cases of low-back pain it is not necessary per-form a blood examination. Indications for blood tests include suspi-cion of infection, other inflammatory processes or malignancies. Thetype of blood tests required will depend upon information gatheredfrom the interview and clinical examination. The following bloodtests will be sufficient for initial diagnostic considerations: Hemoglo-bin (blood percent), white blood cell count, serum creatinine (kidneyfunction), serum calcium (bones), basic phosphates (bones), andblood sedentary rates (general sickness indicator). Additionally, itmay be relevant to examine the urine for blood and white blood cellcounts if there is any suspicion of urinary disease. If the above men-tioned tests are all negative it is highly unlikely that low-back symp-
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toms are a result of any inflammatory process or other metastatic disease.
The HTA-group recommend that reference programs includ-ing guidelines as to what blood tests should be done and in which cir-cumstances. Superfluous examinations are not only expensive butthey also are associated with promoting illness behaviour and indu-cing unnecessary fear on the part of patients.
Prices for the individual blood tests cannot be given becausethe cost of equipment is far greater than costs associated with car-rying out individual tests. Therefore, the cost of singular tests is de-pendent upon the total number of tests that are done. Total costs willonly be reduced minimally if the number of examinations are fewerand conversely will only increase markedly of the number of tests or-dered increases dramatically resulting in the purchase of additionallyequipment and the hiring of additional personnel.
� In 70-80% of cases it is only possible to arrive at the diagnosis “non-specific” low-back pain, even after a thorough examination
� A diagnosis based on a secure pathoanatomical foundation can only bemade in 20-30% of cases
� A diagnosis can only rarely predict the course of the disease� A relevant and comprehensive interview and clinical examination should
always be undertaken during the first consultation with a health profes-sional
� Diagnoses can only in rare situations be arrived upon on the basis of imaging techniques or blood tests alone
� X-ray examinations of the spine should only be undertaken if there is a suspicion of an inflammatory condition, a fracture, a malignancy, or ifpain continues for more than 4 weeks
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6How Do We Address the Low-Back Problem From An Organisational Standpoint?
A considerable increase in the utilisation of both authorised healthcare professionals as well as alternative practitioners in the past yearsis in all likelihood due to a variety of factors including: Our presentlack of diagnostic capabilities, the unwillingness of individuals to “accept” pain, and the widespread practice of undocumented treat-ments. Due to a lack of co-ordination in the authorised health caresystem many “services” are repeated. For example, a patient may beconsulting a chiropractor and a physiotherapist at the same timewithout any communication between these professionals takingplace. X-rays may be taken at the chiropractic clinic and orderedfrom the regional hospital at the same time. This lack of co-ordina-tion results in inappropriate patient strategies, unnecessary costs, andthe promotion of illness behaviour.
THE PRESENT HEALTH CARE SYSTEM
At present, the health care system is composed of primary and secondary sectors. Figure 4 present the structure of the system as wellas the placement of the different health care professions. In the Figure, formal referral routes are presented with arrows and informalreferral routes are presented with dotted lines. Patients can be exa-mined and treated by general practitioners and chiropractors withsupport from the National Health Care insurance. Patients receive financial support from the national health care insurance when beingexamined and treated by physiotherapists and specialists, only whenreferred by a general practitioner
Treatment at hospitals is also dependent upon a referral froma general practitioner, a specialist or a physician on call. Two-thirdsof individuals suffering from low-back pain consult their general practitioners initially and one-third contact a chiropractor (Table 8,page 24). The selected health professional is responsible for the man-ner in which the patient is taken care of initially.
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SUGGESTIONS FOR THE FUTURE ORGANISATION OF LOW-BACK PAIN ASSESSMENT
AND TREATMENT
The HTA-group is in agreement regarding the following recommen-dations regarding the organisation of the manner in which low-backpain should be handled.
� Irrespective of whom the patient consults, examination and treatmentstrategies should be the same.
� Treatment should be carried out in the primary health care sector and preferably in the region where the patient lives. It is important to avoidunnecessary waiting times, the promotion of illness behaviour, and unnecessary costs due to factors such as distance.
� Referrals to specialists should not be undertaken prior to comprehensiveassessment and treatment in the primary health care sector.
� Referral to a specialist or a hospital department should take place quicklyif there are signs of serious disease or if patients do not improve in spite of a 4-week trial of recommended treatment in the primary health caresector.
� We recommend that as a rule patients not seek care at hospital emer-gency wards due to acute low-back pain because most acute wards are notgeared to handle this type of problem.
� Generally, patients should not be hospitalised due to low-back pain.Hospitalisation increases the likelihood of promoting illness behaviourdue to patients’ lack of control over the situation. Inactivity is promotedand costs are high.
� In circumstances of serious illness and extremely severe pain, hospitalisa-tion is of course recommended.
� During treatment close co-operation between relevant health care professionals for example exchanging journals (with patient permission),x-rays, treatment results and so forth.
� Individual patient information is always a central aspect of assessmentand treatment.
In the opinion of the HTA-group, both the formal and informal re-ferral channels presented in Figure 4 should be upheld. The organi-sational planning of low-back pain treatment and assessment shouldbe carried out in accordance with the scope of practice of authorisedhealth care professionals. This is the only way to minimise the dupli-cation of services. We have concluded that a more thorough evalua-tion of the future roles of the differing health professional is not a partof the HTA-commision.
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There are two ports of entry to the public health care systemregarding the treatment of low-back pain; the general practitionerand the chiropractor. As previously mentioned, two-thirds of patientscontact their general practitioner initially and one-third contacts achiropractor.
The scope of practice of the general practitioner when dealingwith low-back pain is to make the initial diagnosis and initiate treat-ment and preventive measures. The general practitioner already hasinformation regarding previous disease, hospitalisations and so forthand therefore plays a central role in the public health care system. Thegeneral practitioner is also the referral source to physiotherapists,specialists and hospital departments as well as being the individualthat does any necessary follow-up work.
The scope of practice of chiropractors includes the diagnosis,treatment and prevention of biomechanical lesions in patients withback-pain.
Due to the fact that chiropractors and general practitioners re-present the most commonly utilised health professions as regards portsof entry into the public health care system for the treatment of low-back pain, underscores the importance of increasing communicationregarding mutual patients with low-back pain. These two health pro-fessions should formalise their communication channels so that rele-vant patient information can be readily retrieved by each group.
Thorough and individualised patient information regardingthe diagnosis, prognosis, and treatment strategy should always be acentral aspect of all patient consultations for low-back pain.
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Primary health care system
Secondary health care sector
General practitioner Chiropractor
PsychologistSpecialistPhysiotherapist
Hospital department/outpatient Emergency ward
Relaxation therapist
FIGURE 4Present health care sector
ACUTE LOW-BACK PAIN
As previously mentioned acute low-back pain is defined aspain of less than 3 months duration. Roughly 50% of patients will befree of symptoms within 3 weeks and 90% within 3 months. Ten percent of patients will experience chronic or recurring symptoms. Mostepisodes of low-back pain resolve by themselves and only rarely dochronically disabling symptoms develop. Unnecessary and perhapsrisky treatments can by themselves contribute to maintaining or evenworsening symptoms and promoting illness behaviour.
In order to prevent unnecessary contact to the health care sec-tor, it is necessary that people are informed about the positive prog-nosis of most episodes of low-back pain. An important aspect of thefuture national strategy regarding the improvement of low-back paintreatment will be public information campaigns. In the future it willbe important to inform the population about when it is appropriateto consult the health care system and when it is not necessary. Peopleneed to be informed about the positive prognosis most commonly as-sociated with low-back pain whether treated or not. The informationmust not dramatise the issue but must also include clear guidelines asto when one should consult a health professional. The HTA-group recommends that public information include the following:
IMPORTANT PUBLIC INFORMATION Many people develop low-back pain.
Important facts to know!
Low-back pain is only rarely a result of a serious illness.
Many people with low-back pain do not need to consult a health professional.
In many cases the low-back pain will resolve within a few days.
It is a good idea to consult a general practitioner or a chiropractor if:
� The pain is severe
� If the pain prevents you from carrying out your daily activitiesfor several days
� If the pain does not resolve within a few days
If your are experiencing the following symptoms contact your doctorimmediately!
� Low-back pain accompanied with an inability to control bladderfunction and a lack of sensation in the groin area.
� Low-back pain accompanied by decreased strength in one or
both legs
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In the opinion of the HTA-group, patients that consult general prac-titioners and chiropractors should be examined, observed and treatedaccording to the guidelines presented below
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First consultation:Interview and clinical examination and determination if
additional diagnostic measures and treatment are necessary
2 weeks of treatmentAccording to needs: Observation or treatment
Conclude case Evaluation athospital (1)
If satisfactory,conclude case
If unchanged orworsened,
re-evaluate
Additional 2 weeks of treatment
Status after 2 weeksDetermine wheather to continue treatment,
order additional tests, or refer
Status after 4 weeksIf satisfactory omprovement:
Conclude or plan continued care or rehabilitation.If unchanged or worsened:
Evaluate the need for further examination or refferal
The suggested course of managing acute low-back pain divided into 2 week modules
1) If suspicion arises regarding fracture, malignancy, infection, or inflamma-tory disease (especially arthritic disease): X-ray, blood ( haemoglobin,sedimentation rate, phosphates, white blood cell count, serum creatinine) and urine tests for the presence of blood. If there is suspicion of lost blad-der function or progressive weakness in the lower limbs acute referral tohospital
It is important that the process including examination and treatmentincludes goal setting as regards treatment results and that both the health professional and the patient are conscious of these goals. Treat-ment results should be evaluated with documented assessment in-struments. In Denmark the Copenhagen Back Research Associationhas developed an widely used evaluation journal and the Danish DiscBase employs a similar instrument. Examination and treatmentresults should be reported to the patient’s general practitioner (con-ditional upon patient’s agreement) in a readily understandable fashion, if the patient has been referred. If the patient wishes, this in-formation should be sent to other health professionals. Suggestionsregarding the future organisation of low-back pain assessment andtreatment should be acted upon.
CHRONIC LOW-BACK PAIN
Chronic low-back pain is defined as pain lasting for more than 3months. Chronic pain will oftentimes lead to sick-leave and many se-ries of treatments. Patients suffering from chronic pain (dependingupon the severity of the problem) are a socially threatened group. Aquick and effective examination and treatment strategy must be im-plemented in order to avoid worsening. Most counties in Denmarkdo not have facilities, which can manage these cases.
The most appropriate examination and treatment program forchronic patients cannot be structured in the same rigid manner as thecase is for acute low-back pain.
An individual strategy must be planned for each patient. X-rays and blood work will frequently be necessary. Generally, a goodrule to follow is that the magnitude of the examination and treatmentprocedures should reflect the magnitude of the problem. In certaincircumstances advice regarding the work place and activation regar-ding increased physical activity will suffice. In other cases the courseshould be addressed in a multi-disciplinary fashion. The latter mayrequire several months of treatment/observation.
� 90% of low-back pain patients will recover spontaneously� Patients should be examined and treated in the primary sector� Treatment strategies should be planned in order to avoid unnecessary
examinations, and if more than one health professional is involved, a highlevel of communication must be established
� Continued evaluation of the course and individual information is impor-tant
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7Summary and suggested areas of focus
WAITING TIMES
Long waiting times for examination and treatment increase the riskof developing chronic symptoms. Waiting times of more than a weekto consult a health professional or 2-3 weeks to consult a specialist isunwarranted. Waiting times for surgery (if indications are clear) should not exceed 2-3 weeks.
The likelihood of returning to work (with an intact work capability) decreases considerably if disabilities last for more than 1-3 months. The need of a long-term and costly rehabilitative periodalso increases as does the likelihood of developing associated pro-blems such as stress, anxiety, and depression. Long waiting times alsoaffect the prognosis of low-back pain negatively because it becomesincreasingly difficult to successfully treat individuals whose status isaffected by these psychosocial factors.
A good opportunity to reduce the number of patients sufferingfrom chronic disabling low-back pain including the indirect costs dueto loss of ability to work depends upon reducing waiting times for relevant examinations and treatment.
INCREASED INTER-DISCIPLINARY CO-OPERATION
The HTA-group is of the opinion that co-operation between the dif-ferent health professionals that deal with low-back pain is unsatisfac-tory. This has been demonstrated in DIKE’s report from 1995 entit-led “The Health Care System’s Handling of Back Pain”. According toour interpretation of the data presented in this report, a continuoustheme in the answers given was the poor communication between dif-ferent professionals. This is due not only to differing ways of addres-sing the problem but also to a lack of formalised communication between health professionals. Possible solutions to this problem havebeen discussed in our group. One possibility is the establishment of“wandering patient files” which go with the patient. This is alreadyin use with obstetrics patients, a system, which results in all relevantprofessionals of being aware of previously undertaken diagnostic measures and treatment. Common post-graduate courses for physi-cians, chiropractors and physiotherapists should be expanded in
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order to promote a more uniform attitude towards low-back pain patients and furthermore that commonly utilised terms/classificationshave more common ground than at present. These courses shouldalso involve other relevant health care groups such as psychologistsand relaxation therapists. The quality of post-graduate education inboth the primary and secondary health care sectors could be enhan-ced by establishing more professorships and associate professorships.
Special courses for other participants on the low-back issue,such as social and occupational workers should be upgraded. Weshould strive after a situation where decisions made by these indivi-duals are in as close agreement as possible with the latest scientificknowledge in the area.
Practice co-ordination must be evaluated and expanded so thatit not only involves private practice and the hospital sector but alsobetween health professionals and the social and communal sectors.
We suggest that a committee with representatives from all re-levant health care professionals be established in order to address theissue of improving inter-professional co-operation and post-graduateeducation.
INDIVIDUAL PATIENT INFORMATION
Chronic low-back pain must be understood to be in an existential “situation” due to the fact that patients may have to learn to live witha certain degree of pain and disability. Even if the most appropriatediagnostic and treatment methods are used, it is not always possibleto cure all patient symptoms. In situations such as these, work andleisure activities must be adjusted in order to maintain as high a levelof “quality of life” as possible, in spite of symptoms.
It is important that patients become activated as early as pos-sible in their treatment programs. This is most readily achieved witha thorough information phase. Patients must be made aware of theirown responsibilities and must also be activated to participate in anactive rehabilitation program. This is the best way to maintain theirsocial position. It may be necessary to repeat information regardingall aspects of the strategy several times in order for patients to developa good insight into the situation. Several health professionals with dif-ferent backgrounds can be involved in the information phase. Infor-mation provided should be individualised and based upon the indivi-dual patient’s situation and needs. The information phase requires 1-2 hours on the part of the health professional depending upon themagnitude of the problem.
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Existing governmental supported programs such as “adulteducation” and “spare-time education” should also be utilised forthis purpose.
It is the opinion of the HTA-group that a strengthened indivi-dualised information effort both in the primary and secondary healthcare sectors is an important area, which should be focused upon. Individualised patient information is so important an area that webelieve that it should be perceived as an independent “service” andpaid for accordingly.
PUBLIC INFORMATION
Information to the general public is an area, which needs to receivemore attention in the future. The population needs to be made awareof our strengths as well as our limitations as regards examination andtreatment. They must be made aware that an episode of low-backpain is not dangerous and that successful treatment results dependupon their participation. If chronic pain develops our diagnostic pos-sibilities become limited, as does the likelihood of curing the patient.This type of information must be made available to the population atlarge. Far too often one witnesses long-term treatment that has notresulted in a complete cure. Patients become disappointed because ofunrealistic hopes and inadequate information. Public informationcampaigns should be planned and carried out with the help of healthprofessionals as well as experts in communication. Additionally, theyshould be repeated several times in order to enhance their effect.
X-RAY EXAMINATION OF THE SPINE
X-rays are very often taken too early in the course of events. X-raysare also repeated within too short a time frame due to poor commu-nication between the general practitioner, the chiropractor and thehospital. This duplication of service is unacceptable also as regardsunnecessary radiation.
Formalised communication channels need to be established inorder to secure that x-rays and their descriptions are always at the relevant place at the correct time. General agreement needs to be attained regarding the practical aspects of taking x-rays as well.
The only way to avoid unnecessary exposures and to increasethe quality of x-rays is to develop guidelines for the taking of x-raysand to develop formalised lines of communication between heathprofessionals. Guidelines should be developed by the relevant profes-sional societies as soon as possible.
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HOSPITALISATION/AMUBULATORY TREATMENT/MULTI-DISCIPLINARY TEAMS
Many patients are hospitalised due to low-back pain (Table 4, page??). It has never been proven that patients benefit from hospitalisa-tion. Hospitalisation is only indicated under certain conditions.
As previously stated, a precise diagnosis cannot always bemade. Hospitalisation can result in differing and confusing informa-tion being given to the patient due to his/her coming in contact withso many different people. Additionally, patients are prone to place theentire responsibility for their conditions on the hospital staff, whichmay lead to increased passiveness and illness behaviour.
The great majority of acute and chronic patients can be exa-mined without the patient being hospitalised. Preconditions for suc-cessful outpatient examinations are; that centres have multi-discipli-nary teams, that only a few people are involved with a patient andthat time is taken to give the patient comprehensive and individua-lised information.
Multi-disciplinary teams with the resources to carry out highquality outpatient examinations and treatment should be establishedin several areas throughout the country. Treatment of severely painedpatients as well as chronically disabled patients can be carried out atthese centres in order to reduce the number of patients that becomehospitalised.
QUALIT Y CONTROL: DATABASES & REFERENCE PROGRAMS
The development of a systematic registration of treatment resultsthrough clinical databases has only recently begun. An example of thiseffort is the Danish Disc Base, which is a nation-wide registration ofthe clinical results obtained from disc herniation operations. This effort will be completed within 1-2 years and the information gathe-red from it will contribute to improving the future treatment of discherniations. Other examples of central registration of treatment results include the database developed by the Copenhagen Back Rese-arch Association (COBRA). It is extremely important that projectssuch as these continue both in the primary and secondary health sec-tors and that adequate funding is made available. These databasesshould utilise validated outcome measurements that are comparable.This is the only way in which we can develop a picture of the overalltreatment effort/results.
The registration of patient data in clinical databases should become standard procedure for every health professional. The resultsobtained from these databases will form the bases of reference pro-
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grams. These reference programs will insure professional developmentbased upon factual evidence.
We should insure that the development of these clinical data-bases is undertaken with the participation of all relevant health pro-fessional associations and that funds are provided for this work. Inter-disciplinary work groups should also be established.
TEACHING/RESEARCH
Many issues relating to the diagnosis and treatment of low-back painhave not been resolved. There is great need to carry out a large num-ber of controlled trials in order to enhance our knowledge.
Formalised post-graduate education and courses should beemphasised in order to insure that patients are treated in accordancewith the newest knowledge in the area. Courses, which emphasise thelatest knowledge regarding the diagnosis and treatment of low-backpain patients, should be carried out by all health professional associ-ations. Increased inter-disciplinary course activity should also bepromoted actively.
We must insure that specialists in rheumatology continue toparticipate in the professional arena of low-back pain. The educationof these specialists should not be limited to “rare” cases as has beenthe case in the last decade. Specialist education should be planned sothat “ordinary” low-back patients are seen regularly as well.
INCREASED KNOWLEDGE OF THE COURSE OF TREATMENT
Our knowledge regarding the documentation of how specific andclear diagnoses are arrived upon as well as which treatments are mosteffective for specific conditions and when these treatments should beadministered is lacking. We also lack information about how patientsare treated presently in the public health sector as well as whether theresults obtained are superior to the natural course of events. Howmany x-rays are taken? How many injections are given? Do these treatments help? The lack knowledge in this area has limited ourHTA-group from arriving at clear recommendations involving eco-nomic issues. In the future it will be necessary to have concrete infor-mation about all of the abovementioned issues in clinical databases.
This information need not take the form of randomised clini-cal trials. The code words in these activities include: systematic regi-stration, prospective observational studies, clinical databases, refe-rence programs and economic planning. The HTA-groups suggeststhat, in addition to establishing data bases and increasing scientific
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work, the mapping out of observational data which describe whathappens to the average person when patients experience a bout oflow-back pain be undertaken. Is there a difference in the treatment given within the same health profession? Are there geographical differences? Does treatment help? Is the likelihood of developingchronic symptoms reduced? Why does treatment seemingly help forsome people but not for others?
What are the costs involved in each treatment? The answers tothese questions and others will make it possible to determine the mostappropriate treatment courses and this information will form theframework for future reference programs.
THE OVERALL CO-ORDINATION OF EFFORTS/PROFESSIONAL FEE SCHEDULES
A will to confront these issues needs to be demonstrated at the highest levels. The re-distribution of resources should not end up resulting in simple money saving acts such as reducing the number ofavailable hospital beds for low-back patients. The re-distribution ofresources should instead channel resources to the areas outlined inthis manuscript. This is necessary in order to effectuate a practicalstrategy.
The project will be made complex by the fact that so many dif-ferent health professions are involved. This will entail considerablechanges in the different health disciplines as well as increased co-ordination between the different groups.
Future public health fee schedules should reward the “infor-mation” phase of any treatment as an independent service. This is themost effective way to secure the needed emphasis of this importantaspect of treatment.
In the opinion of the HTA-group present fee schedules reward“treatment”. Increased research will document which treatment acti-vities are useful and which ones are not. Future professional fee sche-dules can be determined according to scientific merit and can thereforeserve as a regulatory method to enhance the quality of care provided
� Reduce waiting times for relevant examination� Increase the level of information for both the individual patient and for
the population at large� Develop effective channels of communication between health professionals� Establish more multi-disciplinary treatment centres� Develop databases which systematically register examination and treat-
ment procedures� Strengthen research and education
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Low-Back Pain
Volume 2
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50
1The various Danish health professionsthat treat patients with “low-back pain”
There are in Denmark several different health providers, both autho-rised and unauthorised, which traditionally examine and treat pati-ents with low-back pain.
The general prac titioner (specialist in general medicine) in the primar y health sectorIn the Danish health care system the general practitioner has alwaysplayed a central role in the treatment of an individual’s illness. The general practitioner has all relevant information regarding previous illnesses as well as reports from hospital treatments. Due to the centralrole that the general practitioner plays in the health care system he/sheis in a position to prevent “double” examinations and treatment regi-mens. Information regarding examinations and treatment results should be forwarded to the general practitioner if the patient so wis-hes. The general practitioner can, in addition to examining a low-backpatient provide information/advice and initiate treatment such as painrelieving medication or exercise therapy. Preventive treatment and social service can also be initiated. Many physicians use or have know-ledge of manual treatment. The general practitioner can also refer patients for additional examinations or treatment to a physiotherapist,a specialist, or a hospital department. Furthermore, the general prac-titioner can recommend the patient to seek a chiropractor.
The chiropractor in the primary health care sectorThe scope of practice of a chiropractor includes the diagnosis, treat-ment and prevention of biomechanical functional lesions for patientssuffering from low-back pain. Chiropractors received their public authorisation in 1992 and can examine and treat low-back patientsindependently. Due to their educational background chiropractorshave special skills in performing manual therapy including spinal manipulative therapy. Patients receive reimbursement from the healthcare system when receiving chiropractic care whether or not a physi-cian has referred them. In addition to manual treatment the most im-
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portant treatment elements utilised by chiropractors include infor-mation/advice, exercise instruction and intensive training. Soft tissuetreatment is also used but is not a mainstay of treatment. If the chiropractor finds consideration for it, the patient is recommended tosee the general practitioner.
The physiotherapist in the primary health care sectorPhysiotherapists are authorised by the health authorities and upon re-ferral from a physician can treat low-back pain patients in conjunctionwith the general practitioner or hospital physician. In addition theycarry out follow-up status reports of patients and evaluate whetherfurther treatment should be carried out. Patients receive reimburse-ment from the health care system. Physiotherapists inform patientsabout the illness and prognosis and can advise/inform patients regar-ding preventive measures. The physiotherapist carries out functionalexaminations, designs training programs and instructs in exercise the-rapy. Physiotherapists oftentimes carry out manual treatment particu-larly mobilisation and supplemental soft tissue treatment. Some phy-siotherapists use spinal manipulation.
The specialist in the primary health care sectorDifferent medical specialists in the primary health care sector evalu-ate patients with low-back pain. The medical specialities, which pri-marily undertake examinations and evaluations of low-back patients,are rheumatologists and orthopaedic surgeons. Patients who have notexperienced relief of symptoms after treatment at a general practi-tioner, physiotherapist, or chiropractor or certain patients sufferingfrom acute or chronic low-back pain should be referred to specialistsfor further evaluation such as CT-scans – refer to Low-Back Pain Volume 1. Specialists also provide individual information/advice, pre-scribe exercise, and effectuate manual treatments. Advice on preven-tive measures is also undertaken.
PsychologistsPsychological evaluation and advice undertaken by authorised pro-fessionals can be relevant in certain cases. It is not customary that patients consulting psychologists because of low-back pain receive reimbursement from the health authorities.
Unauthorised health care provider in the primary health care sectorTraditionally, other health care providers treat patients with low-
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back pain in the primary health care sector. The relaxation therapistcan carry out individual treatment regimens in private practice or ingroup sessions. Group sessions can be carried out under the “law ofpublic information” at evening school sessions. Treatment at relaxa-tion therapists involves manual treatment of the musculature, mobi-lisation and training. The individual treatment is based upon an ana-lysis of the body at rest and in movement as well as the patient’spsychological and social situation. Information and instruction areintegral parts of the treatment regimen.
Other forms of training/gymnastics (for example Mensendeck)are provided by unauthorised individuals, as is alternative treatmentsuch as acupuncture, zone therapy and dietary advice.
Other players in the primary health sector careSocial workers employed by the local municipality and the WorkmanCompensation Board are important players regarding the low-backpain issue in the primary health sector. They co-operate with healthcare professionals particularly in assisting with patients’ maintainingtheir connection to the job market in periods of long-term sick leave.Other important areas include participation in the determination ofthe degree of work disabilities, accident and work-related compensa-tion and/or disability pensions. Case management should be carriedout in close co-operation with health professionals and only after medical evaluations and reports have been retrieved. The Work En-vironment Institute participates in the preventive and advisory workareas at individual work places, and insurance companies play an important role when accidents have taken place.
Hospital ambulatory/departmentsIn certain situations, a general practitioner or a specialist will refer patients to a hospital department where several different medical spe-cialities may be involved in the evaluation of a patient. This may include rheumatologists, neurosurgeons, orthopaedic surgeons, neu-rologists, or radiologists. Referrals to hospital departments are mostcommonly due to a request for imaging studies such as CT or MRI-scans. Other reasons for referral may be for special treatment formssuch as rehabilitation or spinal surgery. Hospitalisation in order toprovide relief from daily activities can be necessary in special casessuch as when patients cannot take care of themselves at home.
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CO-OPERATION BETWEEN HEALTH CARE PROVIDERS
The treatment of low-back pain patients should to the degree that itis possible be carried out in the primary health care sector and prefe-rably in the area where the patient lives. This will limit unnecessaryillness behaviour and resource waste. Health professionals in the primary health care sector should co-operate in a close fashion for example, by exchanging journal information, x-rays and treatmentresults.
Treatment regimens should be the same regardless of whethera patient consults a general practitioner or a chiropractor. The infor-mation given to patients should also be the same regardless of whoevaluates, informs and advises the patient.
In order to insure the fulfilment of these goals and treatmentquality it is necessary to develop inter-disciplinary “low-back pain”reference programs and quality control systems in the form of nation-wide databases. These quality control instruments must become apart of daily procedures in the primary health care sector.
Patients should only be referred to the secondary health caresector in certain situations. The examination and treatment strategydesign in the secondary health care sector is multi-disciplinary andshould be carried out in an ambulatory fashion as far as possible. Spe-cial diagnostic examinations such as CT or MRI-scans should be carried out in close co-operation between the primary and secondaryhealth care sectors in accordance with an overall priority plan. Results of x-rays and scanning reports should be provided in a man-ner such that relevant information follows the patients throughoutthe treatment sector. More detailed information is provided in Low-back Pain, Volume 1.
A smooth and well functioning treatment system is dependentupon all health professionals being aware of the educational back-ground and professional capabilities of all other authorised healthprofessionals. Inter-disciplinary and inter-sector courses and profes-sional development should be strengthened. These courses shouldalso include representatives of the social services. There is also a greatneed of an increased research in both the primary and secondary health care sectors in order to among other things to record the content and results of the treatment regimens that are carried out onlow-back patients in the present as well as the future.
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2The LPB-group’s analytical method
HTA-BLUEPRINT
Our analyses are based upon a systematic review of material, whichwas made up of systematically chosen elements which when combi-ned represent the HTA evaluation of the singularly analysed techno-logy. The blueprint includes the following:
THE TECHNOLOGY
The area of utilisationWhat is the indication for its usage?Is there agreement regarding the indication?How many patients are involved?What are the relevant alternatives?Alternatives or supplements?
EffectivenessWhat documentation is there for its effectiveness?Is it more effective than other technologies?Is it as effective in our population?
Risk evaluationAre there side effects?Are the potential side-effects reasonable compared to the potential clinicaleffect?
THE PATIENT
Psychological statusDoes the technology result in comfort, discomfort or anxiety?
Social effectsAre daily activities effected?Is the ability to work effected?
Ethical aspectsIs the patient willing to accept the technology?Is it acceptable for society?
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ORGANISATION
StructureShould the technology be located at a few centres?Is decentralisation possible?Is the work distribution between hospitals and the primary health care sector altered?Are new special functions required?Are visitation criteria altered?
PersonnelAre work routines altered?Will the work distribution of different health professionals change?Will it require additional educational for health care personnel?Are there opportunities for employment?
EnvironmentWill the external environment be effected negatively?Is there a risk of a negative effect on the work environment?
ECONOMICS
Direct costsWhat are the direct costs associated with the program, including: side effects, operations, nursing help at home, transportation, or medicine?
Indirect costsWhat are the indirect costs associated with the program such as sick leaveand loss of productivity?
Direct savingsWhat are the direct savings associated with the clinical effect of theprogram?
Indirect savingsWhat indirect savings will result from the implementation of the program?
We have assessed the division between the state, county, municipality,patient and others regarding all of the above mentioned savings/expenses.
The blueprint was used by the panel as a “reminder sheet”. Inseveral situations we did not use all of the individual elements of theblueprint because it would have been irrelevant.
In a few circumstances it was impossible to evaluate the technology in all aspects because we could not find the necessary
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information. It was impossible, for example, to determine how oftenevery technology is used in Denmark because there is no systematicregistration of this type of data.
Generally, the blueprint was a great help to the panel and itcontributed to the systematic evaluation of the technologies.
THE PANEL’S EVALUATIONS
In order to assure that our evaluation process was systematic we developed a scale for the purpose of ranking each item.
1. Firstly, the quality of the scientific foundation for the usage of each technology was evaluated (with guidance from the international HTA-reports).
2. Then we estimated the expected costs for the individual technology.3. Finally, the group arrived at a recommendation of either suggesting
or not suggesting the usage of the individual technology.
THE SCIENTIFIC DOCUMENTATION THAT WAS USED BY THE PANEL� The recommendations, which follow, are based upon scientific documen-
tation and are ranked on a four-point scale. The reader should be awarethat a recommendation regarding a singular technology could either bepositive or negative as regards its usage. Scientific studies can sometimessupport the usage of a particular technology and in other situations recommend that they are not used.
GRADING
The commentary’s weight, Strength AStrong research based documentation, such that there are many relevanthigh quality studies, which support the value of a particular technology.
The commentary’s weight, Strength BModerate research based documentation such that there is at least one relevant high quality study or several medium quality studies, which support the usefulness of a particular technology.
The commentary’s weight, Strength CLimited research based documentation such that there is at least one relevant medium quality study, which support the usefulness of a parti-cular technology.
The commentary’s weight, Strength DThere is no research-based documentation, which supports the usefulnessof a particular technology
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COSTS THAT ARE ASSOCIATED WITH THE UTILISATION OF THE TECHNOLOGY
The next process involved direct cost calculations regarding each individual technology.
LOW COSTS Simple treatment or exercise, which can be carried out by the patient them-selves. This type of treatment can as a rule be carried out at home or at workand does not involve expensive equipment or professional help.
MODERATE COSTSAn ambulatory treatment which is carried out at a hospital or at a health professional in private practice. This type of treatment is not very costly
HIGH COSTSA treatment that requires hospitalisation. This type of treatment is expensive.
THE PANEL’S RECOMMENDATIONS
The LBP-group concludes each treatment evaluation with one of thefollowing recommendations: “Recommended” / “recommended forcertain conditions” / “not recommended”. The numbers given are2,1,or 0 spines
We wish to emphasise that even if a technology has received 2 spineswe do not mean that it should be used in all circumstances. No treat-ments are relevant in all situations. That is why we have supplemen-ted each recommendation with additional commentary. An exampleof this commentary would, for example, be that a particular treat-ment should only be used with certain diagnoses, for a limited periodof time, or in combination with other treatments.
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The scale, which represents our recommendations, will appear as follows:
RECOMMENDED (Symbolised with 2 spines)
RECOMMENDED FOR CERTAIN CONDITIONS (Symbolised with 1 spine)
NOT RECOMMENDED (Symbolised with 0 spines)
As previously stated, the LBP-group will, in addition to providing theevaluations of “recommended” or “recommended for certain condi-tions,” provide explanatory commentary, so that additional clarifica-tion will be presented.
Mostly the reason for a method being “not recommended” isthat there is insufficient documentation for a positive effect in relationto the resources used for the method. In other cases the treatment cannot be recommended, because there is good evidence for the methodbeing of no effect. Only in few cases have the LBP-group evaluatedtreatments as “not recommended” on the basis of documented evi-dence for direct harmful effects. In these few cases it will clearly benoted in the text, that these methods of treatment should not be used.
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3Treatment
DOCUMENTED TREATMENT EFFECT
Ninety percent of patients will recover spontaneously within 12 weeks after experiencing a first-time episode of low-back pain. Fiftypercent will recover within three weeks. The typical course of acutelow-back pain results in a spontaneous recovery for 60-80% of patients irrespective of treatment. It is precisely this factor, which necessitate stringent methodological needs in the design of scientificstudies in determining the clinical effect of different treatments.
There are also other methodological difficulties involved in thedesign of scientific studies dealing with “low-back pain”.
� It is difficult to arrive at a clear diagnostic classification for patients because the pathoanatomical basis for most diagnoses is questionable.
� It is difficult to describe the content of the “tested” treatment because treatments are often individualised and reflect physical findings.
� Studies are designed to evaluate the general effect of a treatment on a large sample population. In reality the treatment involved may be effective, indeed very effective for a sub-population of the large patientsample. This effect may not be “discovered” in the total population sample. This may be due to the type of research design, or due to the possibility that the treatment in question is not effective in the remain-der of the population sample or may in fact be harmful for them.
� The ideal “blinding” of the study group vs. health professional can be difficult to attain.
These factors can individually or in combination with one another result in it being difficult to carry out a reliable scientific study andmake it difficult to interpret previously carried out studies.
ACTIVE OR PASSIVE TREATMENT
One of the greatest errors in the treatment of low-back pain in thiscentury has been the unquestioned usage of passive treatments, often-times initiated when spontaneous recovery has already begun. Passivetreatment runs the inherent risk of promoting passive behaviour
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(illness behaviour) and thereby prolonging the course of illness. Thissituation may lead to chronicity. Patients bear a degree of responsi-bility for the overuse of passive care because they have oftentimesrequested or demanded it due to comforting factors. This however,does not excuse health professionals for their inappropriate choice oftreatment.
Results of clinical research from the past ten years have clearlydocumented that pro-active treatment for both acute and chronic patients represent the most important factor for the continued effectof treatment. Patients have to be motivated to participate in activecare if it is to be successful. This is most readily achieved if patientshave been provided with comprehensive information regarding thediagnosis, prognosis and treatment principles.
TREATMENT STRATEGIES
Prior to determining the treatment strategy, it is necessary to under-take an overall evaluation of the patient’s condition. How great is theproblem? How high is the level of pain intensity? Can the patient manage their work? How has the condition affected the individual’sability to manage daily activities? How long has the condition beenpresent- acute, chronic? The total treatment strategy should be plan-ned in accordance with the answers to the previous questions. The total amount of treatment should reflect the magnitude and durationof the presenting problem.
The ordinary first-time episode of low-back pain will usuallyresolve within a few days and besides advice regarding general life-style and physical fitness, treatment is not usually necessary.
A patient with a chronic condition – perhaps disabling – needsa more complex treatment strategy often made up of several ele-ments. It is important to be aware of the multi-factorial nature oflow-back pain. A simple uni-dimensional treatment is rarely suffi-cient. The goal is therefore to design a treatment strategy that is indi-vidualised and addresses the differing areas of the problem.
PATIENT INFORMATION
The low-back pain patient has a need of comprehensive informationregarding possible pathological mechanisms as well as the diagnosticpossibilities or the lack thereof. Furthermore, the frequently benignnature of most episodes of low-back pain should be underscored. Thechosen treatment strategy should also be discussed thoroughly. Prior
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to beginning treatment patients should be made aware of goals re-garding pain relief, improved functional levels, work and so forth.The duration of treatment as well as eventual risks should also be reviewed.
Treatment strategies for chronic pain patients necessitate theactive involvement of both the health professional and the patient aswell as co-operation between them. It is important to inform the patient that there are no miracle cures and that success is dependentupon sincere participation on the part of the patient. A conversationwith the patient regarding these central principles of illness and treat-ment cannot be completed in less that 20 minutes. It is often impor-tant to carry out another information session 2-4 weeks into treat-ment in order to repeat the most important aspects of the treatmentstrategy.
The following statements include the most important factsabout “low-back pain” – as we know them.
� It is not usually dangerous to experience low-back pain and work will onlyrarely worsen the condition.
� It is almost always best to continue going to work even of there is pain present.
� Long-term sick-leave will not improve the condition – on the contrary,the risk of never returning to work only increases.
THE HTA-EVALUATED TREATMENTS
The most commonly used treatments for low-back pain will be addressed. We begin with the treatments that can be recommendedand follow with those that cannot be recommended. Treatments arelisted in alphabetical order within each category.
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4Treatments which can generally be recommended
TREATMENT METHOD
MANUAL THERAPY
TechnologyManual therapy can be broadly defined as all procedures where thehealth professional uses his/her hands in order to influence a jointcomplex as well as the surrounding tissues. Treatment is given in order to relieve pain and improve function.
The procedures include manipulation and mobilisation, butalso related techniques such as manual traction, myofascial release,and muscle energy techniques. With manipulation a motion segmentof the spine is pushed beyond its normal passive range of movementby means of a thrust.
This treatment is often combined with other methods such assoft tissue treatment and medication in the case of acute pain or ex-ercise in the case of chronic pain.
ContraindicationsThere are a series of factors, which contraindicate manual treatmentin certain conditions. Conditions in which the symptoms are a resultof cancer, inflammation, infection, or when the patient is sufferingfrom serious and/or progressive nerve root irritation are examples of this. In situations where the low-back pain is determined to be offunctional origin but where structural weakness of the bones or jointsas seen for example with severe degeneration, osteoporosis or jointdisplacement, treatment should be appropriately modified.
Documentation- It is not possible to predict which individuals will benefit from
manual treatment (B).- In addition to pain treatment indication is supported by the clinical
observation of functional disturbances of the motion segments ofthe low-back or the joints of the pelvis (D).
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- Manual treatment has been investigated in a multitude of clinicalstudies and there is evidence that acute low-back pain episodes canbe shortened with manual treatment (B).
- There is evidence that manual treatment has a short-term effect onchronic low-back pain, but the literature is inconclusive about long-term benefits. At present there is no evidence of the utility of conti-nued manual treatment (B).
- There is limited evidence of a positive treatment effect with patientssuffering from nerve root irritation (C).
Risk evaluationManual treatment is generally a very safe treatment when relevantcontraindications are addressed. Approximately 25% of patients ex-perience short-lived tenderness in the treated area. Serious complica-tions are considered to be rare. The development of cauda equinasyndrome (nerve root pressure with bladder function impairment)has been described.
Costs
MODERATE COSTSTreatment is primarily administrated in the primary health care sector and isambulatory
Recommendations
RECOMMENDEDManual treatment can be recommended for patients suffering from acute low-back symptoms and functional limitations of more than 2-3 days duration.
RECOMMENDEDManual treatment can be recommended as an initial treatment for acute exa-cerbations of recurrent or chronic low-back pain and functional limitation .
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RECOMMENDED FOR CERTAIN CONDITIONS Manual treatment can be considered as an element of a broader strategy forchronic low-back trouble.
RECOMMENDED FOR CERTAIN CONDITIONS Manual treatment can be considered as an element of a conservative treatment regime in patients suffering from nerve root irritation taking intoaccount the previously mentioned contraindications.
TREATMENT METHOD
BACK SCHOOL/GROUP TRAINING/ERGONOMICS
TechnologyThe term “back school” implies providing information about theanatomy and function of the spine as well as advice on activities re-garding prevention and self-treatment. Teaching is carried out ingroup sessions. It is common to include instruction and practical gu-idance for exercise during back school sessions. The total duration ofthe back school is approximately 4-6 hours. Oftentimes the theoreti-cal instruction is an integrated element of a comprehensive course ofback rehabilitation, which also includes exercise programs. The inte-grated rehabilitation program is usually of 15-30 hours duration,spread over weeks to months. Back school programs are usually ledby physiotherapists, ergotherapists and relaxation therapists.
The traditional back school has been evaluated in several rand-omised trials. The philosophy was guided by “be careful” messages,such as; sit correctly, lift correctly, avoid forward bending, and soforth. In a modern back school the emphasis is to avoid fear, and thephilosophy is to “ignore the pain as much as possible”. This changein attitude has resulted in improved preventive results
Documentation- There are several scientific studies, which have not demonstrated
any short or long-term effects from the “traditional back school”with low-back pain patients (B).
- A “modern back school” where teaching has focused upon “igno-
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ring the pain as much as possible” has demonstrated a preventiveeffect with patients suffering from low-back pain (B).
- Back school should include physical activity and promote attitudeswhich work against the development of chronic disabilities ratherthan “be careful messages” (B).
- Several scientific studies assessing prevention at the workplace haveshown a reduction in sick leave due to low-back pain (B).
- Patients with a well-defined need of rehabilitation such as post-ope-rative disc herniation patients demonstrate a reduced likelihood ofdeveloping chronic symptoms after participating in back school/rehabilitation programs (C).
- As regards lifting technique: Objects should be lifted while “ben-ding at the knees” as opposed to bending the spine forwards if theweight is more than 10-12 kilograms. Relatively few lifts of lightobjects during the course of a days work will in all likelihood notincrease the risk of injuring the spine and therefore do not requirespecial precautions. However, repeated lifting during the day – lightor heavy objects – necessitates specific ergonomic instruction (D).
- As regards the ergonomics of sitting: Uncomfortable furniture should obviously be exchanged in order to achieve a more comfor-table sitting posture. It is important that individuals have the opportunity to “test” different types of furniture prior to purchasebecause factors reflecting sitting comfort and table height may beindividual (C).
- Other areas of ergonomics not relating to sitting and lifting, such asthe psychological environment of the workplace, have not beenthoroughly investigated in a scientific manner and recommenda-tions must therefore be guarded (D).
Costs
MODERATE COSTSAmbulatory treatment.
HIGH COSTSPurchase of teaching aides/ergonomic materials.(From low costs to hign costs depending upon the type of course).
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Recommendations
RECOMMENDED Both the modern back school and group training can be recommended for patients with low-back trouble if there is a clear need of rehabilitation, or whenpreventive efforts are being considered at work places where work tasks can be challenging for the low-back.
RECOMMENDED FOR CERTAIN CONDITIONSIndividual ergonomic instruction – such as advice regarding sitting comfortand lifting conditions can be considered especially if repetitive lifting can be reduced.
TREATMENT METHOD
PAIN RELIEVING MEDICATION
TechnologyPain relieving medication is sold “over the counter” (without pre-scription) (for example paracetamol) or with a prescription if a higher dosage is required such as NSAID (non-steroid anti-inflam-matory medication = pain relieving arthritic tablets).
Stronger pain relieving medication such as morphine deriva-tives can also be utilised.
Documentation- Several studies have documented the effect of paracetamol, NSAID
and stronger analgesics for the relief of acute low-back pain (B). Ithas not been determined whether paracetamol or NSAID is moreeffective (C).
- There are no studies, which document an enhanced clinical effect ofmorphine derivatives compared to either paracetamol or NSAID (C).
- There are no studies, which document any long-term effect of painrelieving medication for chronic low-back pain (C).
- There are no studies which document that utilising several medica-tions at the same time results in additional benefit (C), however, therisk of side-effects generally increases with the utilisation of severaldrugs (B).
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- Several studies have shown that a singular medication may result ina varying effect upon differing individuals (B).
- There is a risk of both physical and psychological dependence whenusing morphine derivatives after as short a time as a few weeks (B).
Costs
LOW COSTS
Recommendation
RECOMMENDED Evaluate if there is in fact a need of pain relieving medication. If there is use a stepladder approach. Increase the dosage after 1-2 days if there is a lack of effect from the initial medication .
First step� Paracetamol up to full dosage If there is a lack of effect, go to the next level:� NSAID up to full dosage If there is a lack of effect, go to the next level:� A combination of paracetamol and NSAIDIf there is a lack of effect, go to the next level:� Tramadol or codeine in conjunction or as a monotherapy (evaluate indivi-
dually). There may be CAVE obstipation from codeine
Individual considerations must be taken into account when usingparacetamol and NSAID. Patients rarely experience benefit of painrelieving medication for more than a month or so (1-3 months).
Stronger medication (morphine derivative) should only be pre-scribed for relatively short periods of time (max. 1-2 weeks). Thesemedications should only be used in periods of severe acute pain, aftersurgery, or if the abovementioned principles have been ineffective.
If patients have sleeping difficulties, sleeping pills in addition topain relieving medication can be used for a short period of time.
Muscle relaxants such as Diazepam have no place in the treat-ment of low-back pain. The possible clinical benefit is overshadowed
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by the risk of physical and psychological dependency even after shortperiods of usage.
TREATMENT METHOD
EXERCISE THERAPY ACCORDING TO MCKENZIE
Technology as a form of treatmentThe background for this exercise program is that movements in thelow-back can either increase or decrease patient symptoms. The the-rapist can guide patients as they repeat certain movements until theyfind the movement which either reduces symptoms or centralizesthem (distal pain moves centrally toward the vertebral column). Pro-grams are designed according to the “preferred” movements and patients are instructed to carry out their individual programs up to several times per day.
There are several studies, which have investigated the McKen-zie method, but most of them are methodologically weak.
There is little risk of side effects for patients, and an advantageof these exercises is that patients assume responsibility for carryingout their treatment and are therefore activated.
DocumentationThere are a few studies, which show a positive clinical effect with patients suffering from acute low-back pain (with or without radia-ting symptoms) (C).
A few studies indicate a positive clinical effect with patientssuffering from chronic low-back pain (with or without radiatingsymptoms) (C).
Costs
LOW COSTS Home treatment.
MODERATE COSTSAmbulatory treatment.
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Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSMcKenzie exercises can be considered as a treatment method for both acuteand chronic low-back pain.
The McKenzie Technology as a diagnostic methodWhen patients repeat a specific movement the preferred type of movement can be determined. This is therefore a useful diagnostic instrument for low-back patients in which the pain source is one ormore discs in the low-back.
Documentation- Several studies indicate that the method has value as both a dia-
gnostic tool and a prognostic indicator (+/- discogenic pain) (B).
Costs
MODERATE COSTSHome treatment.
Recommendation
RECOMMENDED This technique can be recommended as a diagnostic method for both acute and chronic pain syndromes.
TREATMENT METHOD
EXERCISE THERAPY/FITNESS
TechnologyThe therapy consists of a series of specific movements with the goalof increasing muscle strength, improving joint movement and body
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co-ordination by carrying out a systematic training program. The expectation is that the exercise therapy/fitness will improve move-ment restrictions, improve functional levels and reduce pain. Exercisetherapy/fitness can be particularly effective in increasing tolerance forphysical activity and illness behaviour in chronic low-back pain patients.
Documentation for the usage of the technology with acute low-backpain patients- There is no evidence that specific exercises introduced in the acute
phase of low-back pain will shorten the duration of the episode. Patients that are encouraged to remain as active as possible duringthe acute phase seem to do better that those patients performing aseries of specific exercises. There are only a few studies in the lite-rature which deal with this issue (C).
- It is important that patients maintain or improve their physical con-dition through training after the acute pain has resolved (B).
Documentation for the usage of the technology with sub-acute low-back pain patients (from 6 weeks to 3 months)- There are studies, which indicate that back exercises of certain in-
tensity – according to therapeutic instruction- should begin after 6 weeks of continued low-back pain and reduced mobility (B).
Documentation for the usage of the technology with chronic low-back pain patients- Several studies document that a high dosage exercise (twice a week
for a period of 2-3 months) is an effective treatment for chroniclow-back pain (B).
- Patients with chronic low-back pain who have psychological pro-blems and are at risk for losing their contact to the work force canin certain situations have additional benefit from a combination oftraining/ergonomic instruction/psychological intervention (D).
Costs
LOW COSTSHome exercises.
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MODERATE COSTSAmbulatory treatment.
Recommendations
RECOMMENDED The treatment can be recommended for patients suffering from low-back painfor 6 weeks or more.
RECOMMENDED FOR CERTAIN CONDITIONS Can be considered as a preventive effort for patients who have experienced several episodes of low-back pain.
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5Treatment methods that can be recommended in certain conditions
TREATMENT METHOD
INJECTIONS IN THE MUSCLES, JOINTS,AND LIGAMENTS AND IN CLOSE APPROXIMATION
TO NERVES, INCLUDING ACUPUNCTURE
TechnologyThe term injections is meant to include the injection of liquid or acu-puncture needling -dry needling- in soft tissues for example in “trig-ger points” = special pain centers (muscles), ligaments, fascia, bursae,in joints, near nerve tissue for example in a joint cavity, or an epidu-ral injection in the spinal canal.
Injection treatment can be carried out in order to provide relief or as a diagnostic measure. Relief of pain may provide evidencethat the site of injection was in fact the source of pain.
Treatment can involve/use any of the following:a. Dry needling/acupunctureb. Hypertonic salt waterc. Anaesthesia (local anaesthetic)d. Steroidse. NSAIDf. Phenol g. Combinations of b,c,or d.
The most common combination is an anaesthetic + steroid usually ina combined volume of 5-10 ml.
Usually a single injection is performed but there may be a needof 1-2 repetitions during the course of a month. The total number ofinjections should not exceed 3. The time interval between injectionsis dependent upon the liquid injected as well as the volume. Acupunc-ture can be performed by unauthorised health workers provided thatit is done under medical supervision.
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Side-effectsOccasionally (less than 1 out of 10,000) a serious complication cantake place in the form of a local infection around the area of the injection. The risk of infection depends upon the content of the injection.
Repeated injections with steroids involve a risk of serious systematic side effects.
Injection with phenol is not recommended due to the fact thatpermanent damage to the skin and connective tissue in the area of injection may take place.
Repeated injections increase the risk of passivity and illness behaviour on the part of the patient and we therefore recommend extreme caution. Due to this we advise that injection treatment becombined with patient activating strategies.
TREATMENT METHOD
INJECTIONS IN TRIGGER POINTS, MUSCLES AND
LIGAMENTS
Documentation- There is limited and non-conclusive research based documentation
regarding the diagnostic or clinical value of injections for acute low-back pain (C).
- There is limited research based documentation for either the dia-gnostic value or short-term clinical effect with chronic low-backpain and no documentation of long-term effects (C).
Costs
MODERATE COSTS
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Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSFacet joint injections cannot be recommended as a treatment but they may be considered as a diagnostic procedure in certain situations.
TREATMENT METHOD
FACET AND SACROILIAC JOINT INJECTIONS
Documentation- There is only limited scientific evidence of any clinical effect regar-
ding acute or chronic low-back trouble (C).- There is no documentation of any clinical effect of injecting the
sacroiliac joints, but there is some documentation for the utility ofthis method as a diagnostic tool (C).
Costs
HIGH COSTSThe treatment is carried out in an ambulatory manner at hospitals with imaging guidance.
Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSFacet joint injections cannot be recommended as a treatment but they may be considered as a diagnostic procedure in certain situations.
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TREATMENT METHOD
EPIDURAL INJECTIONS
Dokumentation- There is limited research based evidence that steroid injections with
or without local anaesthetic have a pain relieving effect for weeks/months with acute low-back pain patients with radicularsymptoms (C).
- There is no evidence of any clinical effect with acute low-back patients without radiating symptoms or with chronic low-backpain patients (D).
There is evidence of a risk of rare but serious complications from injections (A).
Costs
HIGH COSTS
Recommendation
NOT RECOMMENDED
TREATMENT METHOD
ACUPUNCTURE
Documentation- There is a limited amount of research based evidence for a short-
term pain relieving effect with acute or chronic low-back pain patients but no evidence of any long-term effect (C).
Costs
MODERATE COSTS
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Recommendation
NOT RECOMMENDEDWe do not recommend that acupuncture be used for low-back pain patients because the possible clinical benefits do not outweigh the costs and eventualrisks.
TREATMENT METHOD
MASSAGE AND HEAT/COLD THERAPY
TechnologySoft tissue treatment, which increases blood circulation or decreasestension.
Documentation:- There are a few studies, which demonstrate a short-term pain
relieving effect but no long-term effects (B).
Costs
LOW COSTSHome treatment.
MODERATE COSTSAmbulatory treatment .
Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSWe do not recommend this treatment generally but it can be considered forpain relief for localised muscle pain or for initial pain relief/relaxation prior tousing other documented treatment methods such as manipulation, exercisetherapy and so forth.
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TREATMENT METHOD
BACK SURGERY
The technologyThere are several different operative methods as well as operation types for differing conditions in the back. In the text that follows ope-ration types are grouped into three main categories. This report willnot deal with all of the different operative methods involved for example in treating fractures or different anomalies of the spine suchas scoliosis:
A: Operation or re-operation for a disc herniation.B: Operation for spinal stenosis (narrowing of the spinal canal).C: Operation for spinal instability.
There can of course be situations where a combination of the abovementioned procedures or indeed all of them may be involved. Ope-rations are rarely performed purely on the basis of low-back pain butmore often due to low-back pain with radiations to the leg or legs.Dominant leg pain will more frequently result in surgical interventionthan low-back pain alone. There is a lack of prospective controlledclinical trials for all of the procedures mentioned.
Both neurosurgeons and orthopaedic surgeons perform theabove mentioned operations. Local and regional organisational fac-tors determine which medical departments perform the different procedures described. The important developments in spinal surgerynecessitate that both of the medical specialities involved need to co-ordinate their activities to a greater degree so that patient selectionand chosen operative techniques in all regions are conducted accor-ding to a common consensus.
The total number of surgeries (A, B, & C) performed in Den-mark number approximately 4,000 per year.
Disc herniationThe technique used for performing first-time or repeat surgery fordisc herniations is well known and requires low-tech equipment. Theprocedure is carried out by means of a partial laminectomy (hemila-minectomy). A small amount of bone tissue is removed and the ex-posed nuclear and disc tissue is removed. A repeat surgery is essen-tially the same procedure but more bone tissue is removed prior toremoving scar tissue.
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IndicationFirst-time surgeries are not usually performed before conservativetherapy has been attempted for 4-6 weeks. In addition there has to bea positive correlation between clinical findings and imaging reports.Subacute operations may be performed if a patient is experiencingprogressive weakness in the leg during the course of a few days or ifthe pain is extremely severe in spite of medication.
Acute operations (within hours or days) are carried out if thereare signs of cauda equina syndrome.
CommentaryThree thousand operations of this type are performed per year. In thecounties that have departments of neurosurgery operations are pri-marily carried out at these departments. However, these proceduresare also carried out at orthopaedic departments particularly in coun-ties in which there are no neurosurgery departments.
In addition to the described operation technique other tech-niques such as microsurgery (involving a microscope) may be used.This type of surgery has not demonstrated shorter post-operative hospitalisation stays. It seems as though microsurgery results in a greater number of relapses.
Documentation: - There are many relevant but uncontrolled studies, which demon-
strated a long-term effect on pain after surgery. Only a single ran-domised study compared the results of operations to conservativecare (C).
- Success rates are in the range of 70-90%. The risk of serious com-plications is rare (A).
Costs
HIGH COSTS
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Recommendation
RECOMMENDEDSurgery can be recommended provided that the above mentioned criteria arepresent.
TREATMENT METHOD
SPINAL STENOSIS
Procedures for spinal stenosis involve well-known and low-tech instrumentation. This procedure involves a more comprehensiveremoval of bone tissue and nerve decompression than disc herniationprocedures.
The diagnosis is made with MR-scans or with functional myelography eventually supplemented with CT-scans
IndicationsThere must be a clear correlation between long-term functional distur-bances, objective clinical findings and imaging results before consideringthis procedure.
CommentaryThese operations are carried out at either neurosurgery or orthopae-dic departments. Approximately 300 are performed per year.
Dokumentation- There is scientific documentation as regards pain relief in 60-70%
of patients when the previously mentioned criteria are present (B).- Symptom relief of more than a few years has not been proven but
benefits can be difficult to demonstrate due to the progressive nature of degenerative processes (D).
Costs
HIGH COSTS
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Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSThis procedure can be recommended in certain instances if the previously mentioned criteria are present.
TREATMENT METHOD
STABILISING BACK SURGERIES
Stabilising back surgeries require more operation equipment, speciali-sed tools, metal for fixation, and bone transplant material (preferablyfrom the patient or from a bone bank). This procedure is thereforeboth a low and a high-tech procedure. This operation (3-8 hours) ismuch more invasive that the previous procedures. Particularly long lasting operations may require blood transfusions. This type of opera-tion results in more complications than the previously discussed pro-cedures and complications may be of a very serious nature.
Twenty to forty per cent of patients require additional surge-ries because of a lack of healing of the bones.
IndicationsThe surgical candidate must undergo a comprehensive examinationprogram possibly involving a test period during which he/she wearsa corset. This may help in determining whether a “stiffening” opera-tion will be helpful. The radiological examination procedures are alsoconsiderable. In addition to plain x-rays one or several of the fol-lowing examinations may be involved; MR-scan, myelography andCT-scan.
In order to determine whether there is a clear indication forsurgery there has to be a clear correlation between the history, thesymptoms, the objective examination and the imaging results.
CommentaryFive to six hundred patients undergo this procedure each year. Painmay be due to instability or painful movement. Patients will often-times have undergone operations for disc herniations or spinal steno-sis.
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This type of operation should be performed in a few centresonly and in close co-operation between neurosurgeons, orthopaedicsurgeons and rheumatologists. The uncomplicated cases can be ope-rated on in smaller centres in co-operation with major centres.
Documentation- There is no clear scientific documentation for pain relief or func-
tional gains. There is empirical evidence that states that 50-70% ofall patients experience benefit if the previously mentioned criteriaare present (D).
Costs
HIGH COSTS
Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSThis procedure can only be recommended in particularly well chosen cases in which the patient has clear surgical indications.
CommentaryWork is going on to define more certain operation indications andprognostic factors.
Costs can run up to 80-100.000 DKK per operation. This pro-cedure is still in a developmental stage and more controlled studiesneed to be carried out.
TREATMENT METHOD
BED REST
The technologyIn cases where there is a suspicion of disc herniation bed rest (23-24hours per day) is carried out in order to unburden the back.
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Documentation- There is evidence that even a few days of bed rest for patients where
there is no suspicion of disc herniation increases functional loss andenhances the likelihood of chronic symptom development (B).
- There is empirical evidence that patients who are suspected of suf-fering from disc herniations will benefit from bed rest of up to oneweek’s duration. This benefit can result in long-term pain relief forsome patients (D).
Costs
LOW COSTS Home treatment.
HIGH COSTSHospitalisation.
Recommendation
NOT RECOMMENDEDBed rest for patients not under suspicion for disc herniation should be dis-couraged. If patients are suffering from severe pain, bed rest can be consideredas a pain relieving measure for a maximum of 1-2 days.
TREATMENT METHOD
TRANSCUTANEOUS NERVE STIMULATION
The technology- There are several studies dealing with this treatment but results are
unclear. Some studies demonstrate an apparent pain reduction in patients suffering from chronic symptoms (B).
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Costs
LOW COSTS Home treatment.
Recommendation
RECOMMENDED FOR CERTAIN CONDITIONSWe do not recommend this treatment as a commonly used procedure. It can be considered in certain patients suffering from chronic pain.
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6Treatments that cannot be recommended
TREATMENT METHOD
CORSETS
The technologySpecially sown material corsets or soft material belts.
Documentation: - A positive clinical effect has never been demonstrated and there is
little scientific data (D).
Costs
LOW COSTS
Recommendation
NOT RECOMMENDEDCannot be recommended.
TREATMENT METHOD
TRACTION
The technology:This treatment is carried out with an apparatus, which stretches theback as well as the paraspinal structures.
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Documentation- There are approximately 20 studies of good scientific merit. These
studies do not indicate a clear clinical effect of traction with eitheracute or chronic patients with or without sciatica (A).
Costs
MODERATE COSTSAmbulatory treatment.
HIGH COSTSHospitalisation.
Recommendation
NOT RECOMMENDEDWe do not recommend this treatment for low-back pain with or without sciatica. There is a risk of symptom exacerbation in rare circumstances
TREATMENT METHOD
ULTRA SOUND, LASER, SHORT-WAVE THERAPY
The TechnologySoft tissue treatment with ultra sound/laser/short-wave therapy.
Documentation:Several studies have been carried out. There is no documented clini-cal effect (A).
Costs
MODERATE COSTS
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Recommendation
NOT RECOMMENDEDThese therapies cannot be recommended.
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7Prevention
The most important elements in the design of effective preventive efforts have already been mentioned in this report. This chapter willtherefore summarise the most important areas that should be focused on.
The scientific evidence regarding proven prophylactic inter-ventions is not strong. The literature on prevention is sparse. In addi-tion, social and cultural factors in different societies will greatly effectthe manner in which the individual patient as well as society at largewill perceive concrete prophylactic projects. This makes it difficult todetermine how prophylactic measures in one society will work inanother.
� As the case has been for international consensus reports dealing with the area of prevention/prophylaxis our group has been unable to find suf-ficient data to undertake an HTA-evaluation of the individual measures.Due to the same reasoning we will NOT grade the individual interven-tion’s strength.
Prevention can be divided into two different “areas of effort” whichare defined according to the group, which is the focus of the inter-vention.
Primary prophylaxis is defined as interventions for people whohave no low-back symptoms either at the present time or in the pastand who have no identifiable risk factors. Examples of primary pro-phylaxis include ergonomic changes at home or at work, advice re-garding physical activities, information campaigns to the generalpublic about how to react to an episode of acute low-back pain andso forth.
Secondary/tertiary prophylaxis refers to interventions for indi-viduals who have already suffered from low-back pain. The effort isprimarily aimed at preventing a reoccurrence of symptoms (second-ary prophylaxis), or reducing the effects of poor health or reducingthe social costs of already existing low-back pain so that chronic disabilities are prevented (tertiary prophylaxis).
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PRIMARY PREVENTION
Primary prophylaxis is often seen in public information campaigns, inwhich the public at large is warned about improper behaviour. Thesecampaigns have rarely shown their effectiveness. A short-term infor-mation campaign has no long-term effect on the health attitudes/behaviour of the general public. Only back school carried out at workplaces (page 66) has demonstrated a preventive effect as regards sick-leave due to low-back pain .
Ergonomic interventions have only demonstrated a marginaleffect in several scientific studies. A reduction in the frequency of heavy and repetitive lifting and the elimination of inappropriate workstations (page 66) can have a certain effect on the frequency of futureepisodes of low-back pain. When workers feel “comfortable” it is doubtful that further ergonomic intervention will result in any mea-ningful gains. It is therefore most important to weigh any possible intervention with possible benefits.
It is therefore important to regard most “general” ergonomicinitiatives as being geared to improve the job satisfaction rates of wor-kers rather than an effort to actually reduce sick leave due to low-backpain. In other words: Ergonomic improvements can have a great effecton the comfort levels or workers without reducing sick leave.
We recommend that future primary prophylactic initiatives focus upon the avoidance of clearly inappropriate work situationssuch as the elimination of very heavy or repetitive lifting, or suddenunexpected movements which can stress the back. This may reducethe number of accidents and other work-related injuries.
Other ergonomic projects such as the changing of all non-ad-justable writing desks to desks which can be adjusted in height have aprimary goal of improving comfort as opposed to reducing the num-ber of work related injuries and accidents. The economic priorities related to differing prophylactic interventions should be based uponrealistic expectations as regards possible meaningful results.
We must be aware of the fact that information campaigns withslogans such as: “4 hours of physical activity a week”, or “10 minutesof exercise at every break”, or “an hour a week at a fitness centre” andso on have not demonstrated any short or long term effect. Experiencetells us that individuals who are not ill are not motivated to participatein preventive activities. There is also the risk of a counter productiveeffect from messages of this sort. It is important that the central mes-sages of information campaigns are not moralising. Information
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should be presented in a neutral fashion such as explanatory informa-tion about the function of the back, examination techniques andavailable treatments. Advice about how future patients should tackletheir first episode of low-back pain would also be helpful. This type ofmessage does not demand something of the individual in the immedi-ate future such as doing something that will promote health but ratherincreases the publics level of knowledge about the low-back issue. Informed individuals will possible react more rationally if they encounter a future episode of low-back pain.
SECONDARY/TERTIARY PROPHYLAXIS
One of the most important goals of this type of prophylaxis is to pre-vent an ordinary acute episode of low-back pain from developinginto a chronic and disabling low-back condition. Many risk factorscan contribute to the development of chronic pain in the 10-15% ofpeople with acute low-back pain that develop chronic symptoms.Particular factors such as long-term sick-listing, psychological stressor depression, and poor job satisfaction play important roles. SeeLow-back Pain vol. 1 pages 26-28.
In the future it is important that the average course of treat-ment addresses these known risk factors in order to decrease the likelihood of chronic pain development. In order to reduce illness be-haviour double treatment should be avoided. It is also important toreduce waiting times for examinations and treatments. Patients riskdeveloping chronic symptoms while simply waiting for further treat-ment or examinations. We refer to Low-back Pain vol. 1 page 43.Lastly, we must make sure that patients are provided with thoroughinformation about their condition, treatment, prognosis, and preven-tion so that uncertainties and anxiety levels are reduced.
An important area which should be focused upon is providingspecial rehabilitation programs for patients who have experiencedlong-term low-back pain or serious disabilities regarding the abilityto manage daily activities, so that functional capacities can becomenormalised or at least as good as they can be. Studies show that re-habilitation programs for patients who have undergone disc surgeryinsure that a larger number of patients return to a normal level dailyfunctioning at their jobs and at home than if a rehabilitation programis not completed.
Further research is still necessary in order to identify the mostimportant secondary/tertiary efforts where the effect of the interven-tion is greatest related to associated costs.
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SOCIAL ASSISTANCE PROGRAMS
An area, which requires additional focus, is the co-operation betweenhealth professionals, the social sector and the work place.
The opportunity to return to work in a flexible manner such asshort or long-term “protected jobs” is important in order to securethat individuals suffering from severe acute pain can maintain theirjobs.
The rehabilitation of injured workers should also be co-ordinated by the abovementioned sectors.
It is important that all relevant social services are utilised whenneeded by individual patients. They include:
- Sick-listing.- An agreement in which sick leave support is paid from the first day
(§28).- Declarations suggesting that workload be lessened.- Work tests.- The design of work places and tools.- Wage support during periods of re-schooling.- Assessing workers capabilities.- Flex jobs.- Protected jobs.Additionally, we refer to the Service Law of July 1, 1998.
“The sick-listing of patients should as far as possible be done by general practitioners in order to secure that he/she retains their pri-mary role in the co-ordination of continued treatment (see page ??).”
Every individual county should take the initiative to developand maintain close co-operation between all professionals involved.In order to secure that all relevant social services are provided to in-dividual patients, it is necessary to have procedures clearly delineated.
The previously mentioned secondary/tertiary prophylacticmeasures may appear to be rather obvious. However, they are notcarried out in reality because the health care sector cannot offer thenecessary rehabilitation and work hardening programs due to a lackor co-ordination between the different players and due to a lack of resources.
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8Economics
We mentioned several of the difficulties in calculating the total coststo society of low-back pain in “Low-back Pain, Vol. 1”. There is alack of clarity about the total treatments provided in both the primaryand secondary health care sectors. Different methods of calculationresult in different conclusions. Lastly, it is difficult to calculate manyof the individual services. How much does it cost to carry out a x-rayexamination. Should one include the costs of maintaining a x-ray unitor building costs? What about heating the premises? It is difficult toseparate singular costs out of the total costs of running a departmentbecause many different activities take place in the same area by thesame personnel.
We calculated in “Low-back Pain, Vol.1” that the total yearlycosts related to low-back pain was approximately 10 billion DanishDKK of which 3 billion DKK were direct costs and the remainder in-direct costs.
COSTS OF THE SINGULAR ACTIVIT Y
It is easier to calculate treatment costs than total costs to society. Inthe Appendix we have attempted to clarify the costs associated withdifferent treatments for the individual patient that are typically offe-red in the health care sector. In order to simplify the problem costs arebased upon a typical 4-week examination and treatment course inwhich a particular examination and treatment activity is carried out.We point out whom it is that pays for treatment; the commune, thestate or the patient.
Note that we have chosen typical and common examinationand treatment courses but one can easily imagine many other equallytypical courses.
The reader should be warned against comparing the cost ofone type of service with another and thereupon concluding that fundscan be saved if we always utilise the least expensive service. For example, 4 weeks of pain relieving medication treatment is muchcheaper than a 4-week course of treatment at a physiotherapist or achiropractor. Treatment types are rarely comparable. The content oftreatments differs, as do patient needs.
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Calculations should primarily serve to provide us with an over-view of the costs associated with an individual course of treatmentand which extra costs can be incurred if inappropriate treatment isbegun.
BOX ECONOMIC ANALYSIS OF A COURSE OF TREATMENT FOR “LOW-BACK PAIN”The table on page 94 contains a so-called box-economical analysis.In other words a view of which boxes finance the given examples ofhealth services for patients with back pain. Treatment at a relaxationtherapist is not subsidised by the public health care system and pay-ment is therefore made by the patient alone. On the other hand a con-sultation at a general practitioner or a specialist is fully paid for by thepublic health care system. Medication is partially subsidised. Patientsreceive compensation (in the table we have used 50%). As regardssupport for privately practising physiotherapists and chiropractorssupport from the public health care system is 40% and 30% respec-tively. Hospital treatment is completely paid for by the county.
Pay during sick leave is paid for by the employer, public em-ployers, and the commune. Private employers pay for the first 2 weeks of sick leave while the remaining sick leave period is paid forby the commune in which the individual resides. Public employerspay for the entire sick leave period. Employers who continue to payfull wages under sick-leave are entitled to receive the support that thecommune would have paid to the employee during the sick-leave period. The state refunds 75% of the costs incurred by the communefor sick-leave wages.
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SAVINGS IF “RECOMMENDED TREATMENT COURSES” ARE CARRIED OUT
In order to arrive at the possible economic savings attainable if westrive to carry out desired treatment courses, the LBP-group has con-structed 2 typical treatment courses. We have calculated the directcosts as well as the costs associated with sick-leave benefits.
For an example we have chosen treatment of an acute low-back disc herniation. In both of the “constructed” cases conservativetreatment has failed and surgery has followed. We preclude that sur-gery has been successful and that the patient returns to work in goodhealth. The examples are typical of long-term treatment courses.Upwards of 10,000 patients per year are treated for acute low-backdisc herniations for shorter or longer periods of time. Conservativetreatment is successful in the majority of patients but surgery is necessary for 25-30% of patients. Patients are typically sick-listed for4-12 months in conjunction with treatment for disc herniations. Asdescribed in Low-back Pain, Vol. 1 many acute episodes of low-back
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Examples of treatment courses and the division of boxes of typical services in DKK4 WEEKS OF TREATMENT IN THE PRIMARY HEALTH CARE SECTOR:
Cost categories County Municipality The state Patient In total
Public health insurance Hospital sector
General practitioner *) 396 0 0 0 0 396
Physiotherapist in private practice **) 576 0 0 0 864 1.440
Chiropractor in private practice **) 221 0 0 0 1.104 1.325
Medical specialist **) 907 0 0 0 0 907
Medicin- inexpenive 28 0 0 0 28 56- expensive 98 0 0 0 98 196
Relaxation therapist 0 0 ****) 0 1.200 1.200
Hospital treatment 0 24.246 0 0 0 24.246
2 weeks of hospitalisation for a disc herniation operation 0 17.964 0 0 0 17.964
Ambulatory treatment 0 7.141 0 0 0 7.141
PAYMENT OF SICK-LEAVE BENEFITS***)
Sick-leave benefits *****) 0 0 672 2.016 0 2.688
*) From the Department of Health Insurance, Århus County.**) The office of the Department of Health Insurance. 1998, Schultz law service – Health laws. Schultz Information.***) On the precondition that sick-leave benefits are paid entirely by the commune whereupon the state refunds 75% of the costs.****) Some communes subsidise treatment costs.*****) Per week.
pain (including those without disc herniations) lead to long-term sick-listing, much treatment and the occasional hospitalisation. We as-sume that many more than the 10,000 disc herniation patients gothrough similar courses of treatment as we described. The exact num-ber is impossible to present.
The recommended coursePatients receive treatment in the primary health care sector. Only thenecessary health professionals are involved and there is good com-munication between them and no unnecessary waiting time. A phy-siotherapist or chiropractor carries out the treatment in associationwith the patient’s general practitioner. As there is no effect from theadministered treatment the patient is referred to the spine center ofthe hospital. There is no effect of the hospital treatment but treatmentis carried out without wasting time. This is followed by a CT-scan,surgery and rehabilitation (also without undue waiting time).
The non-recommended courseThe patient is examined and treated by several health professionals inthe primary health care sector. There is insufficient communicationbetween the health professionals and unnecessary waiting times develop. Due to a lack of improvement the patient is hospitalised ontwo different occasions for further examination and treatment. Thefirst hospitalisation was of 2 weeks duration during which conserva-tive treatment was attempted without clinical results, and a CT-scanwas ordered. There is considerable waiting time both for the CT-scanas well as for surgery. At present, waiting times for a CT-scan are ap-proximately 3 months as are waiting times for surgery. In this exam-ple, rehabilitation will be necessary for a longer period of time thanin the desired course of treatment due to the fact that the physicalstate of the patient is relatively worse after surgery and the manymonths of waiting.
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The Figure, which follows, illustrates the two different treat-ment courses plotted against a time axis. The recommended courseends with a discharge after 20 weeks while the non-recommendedtreatment course ends with a discharge after 44 weeks.
96
T R E AT M E N T F O R D I S C H E R N I AT I O N
Generalpract.
Phys.Chiro.
Backcenter
OperationRehabilitation
The desired course
SICK-LISTED Healthy
0 4 8 12 16 20
ANALGESICS/NSAID
The undesirable course
SICK-LISTED
Generalpract.
Phys. Chiro. Waitingtime
Medicalspec.
Waitingtime
Hosp
italis
atio
n
Waiting time OperationRehabilitation
Healthy
0 4 8 12 16 20 24 28 32 36 40 44
ANALGESICS/NSAID
Time axis/weeks
Time axis/weeks
COSTS
As we can see from the following calculation the “undesired treat-ment course” is more than twice as expensive to carry out as the“desired treatment course”. Patients in the “desired treatmentcourse” in all likelihood experience a greater degree of patient satis-faction. There is a greater chance of achieving a complete cure andmaintaining work capabilities for these patients as well. However,our calculations only relate to economic costs.
Costs associated with the “desired treatment course” (in DKK):General practitioner 384.-Physiotherapist/Chiropractor (average) 1.390,-Back center 7.141,-Hospitalisation and operation 17.964,-Rehabilitation (alternative 1) 2.000,-Inexpensive + expensive medication 1.008,-Sick-leave benefits *) 53.760,-In total 83.647,-
Costs associated with the “undesired treatment course” (in DKK):General practitioner 384,-Physiotherapist 1.440,- Chiropractor 1.325,-Medical specialist 907,-First hospitalisation 24.246,-Hospitalisation and operation 17.964,-Rehabilitation (alternative 1) 2.000.-Inexpensive + expensive medication 2.772.-Sick-leave benefits *) 118.272.-In total 169.310.-
*) In an economic analysis one should also include production loss in conjunction with sick-leave. Due to the uncertainties associated with loss of productivity we have included thecosts associated with sick-leave benefits instead.
One should also include the costs associated with disability pensionsfor patients, who have not been helped by treatment and must leave thework force. Patients, who receive the middle level of pension, are paid9,097 DKK per month, which results in a yearly cost of 110,000 DKK.Should an individual receive a disability pension for the rest of his/herlife this will result in a considerable amount of money.
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The implementation of improved and more effective treatmentcourses will in addition to saving money in the health care system alsoreduce costs related to sick-leave benefits and disability pensions.
HOW CAN THESE SAVINGS BE ACHIEVED
It is important to underscore that the desired treatment course can enhance the likelihood of achieving satisfactory treatment results thusdecreasing the likelihood of chronic symptom development in addi-tion to considerable savings.
The amount of savings is particularly dependent upon our ability to succeed in the following:
� To avoid “expensive” waiting times� To achieve the best possible communication between the involved health
professionals and the relevant social authorities.� To avoid unnecessary and meaningless examinations and treatments
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9Concluding Comments
The first meeting of our Low-back pain group that produced “Low-back Pain, Volumes 1 and 2”was held in Copenhagen on the first ofAugust 1995. Since that time, there have been over 5 million contactswith patients in the primary and secondary health care sectors due tolow-back pain. Some patients have experienced severely disablingsymptoms while others have experienced a lesser degree of trouble.
Our work group is very aware of the size of the low-back painproblem and it has been very gratifying to note that we have discer-ned a willingness to tackle the problem seriously at all decision ma-king levels of the health care system. The awareness of this issue wasalready great during our work on “Low-back Pain, Vol. 1” Since thepublication of our first volume, health professionals and decision ma-kers in the health care system have participated in intense professio-nal and organisational discussions based upon our initial recommen-dations. Many new initiatives have already taken place. For example,in over 7 counties (as of June 1998) there have been inter-disciplinarymeetings, which have dealt with the possibilities of implementing ourrecommendations at the local level.
Professional developments in the international forum regar-ding the “back problem” are being carried out at a rapid pace. Newknowledge in research reports and evidence based clinical “guide-lines” are also being published at a pace, which far surpasses pre-vious rates. It is already time to consider when we should begin plan-ning the updating of “Low-back Pain Vol. 1 & 2”. In all likelihoodthis should be carried out within 3-4 years.
Only if we are at the forefront of international developmentswill we be able to offer optimal treatments at the local level. It is therefore important to conclude with the same message that we pre-sented in Low-back Pain Volume 1. That a massive effort involvingincreased research, post-graduate education, the implementation ofinter-disciplinary reference programs and guidelines and improvedprofessional co-operation and communication are all essential, if weare to optimise our efforts in the assessment and treatment of lowback pain patients.
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APPENDIX
Examples of costs associated with the treatment of “low-back pain”
TREATMENTS IN THE PRIMARY HEALTH CARE SECTOR
Examples of the costs associated with the assessment and treatmentof low-back pain patients in the primary health care sector are shownin Table 1. The calculations begin with a hypothetical treatmentcourse lasting for a period of 4 weeks. The fee schedule for consultinga general practitioner was provided by the National Public Health Insurance, Århus County, 1997. The fee schedule for physiotherapists, chiropractors and medical specialists were provided by the National Public Health Insurance Department of Negotiations andare given as 1997 figures. The fees for relaxation therapists and medication costs are based upon evaluations by the expert panel.
General PractitionerThe fee schedule for consulting a general practitioner was provided by the National Public Health Insurance, Århus County, 1997. Duringthe period of treatment in our hypothetical model we assumed that apatient would consult his general practitioner 4 times. The cost of a consultation is 96 DKK and this covers a consultation during opening hours from Monday to Friday from 8 a.m. to 4 p.m.
Practising Physiotherapist The fee schedule for consulting a physiotherapist (1997 figures) hasbeen provided by the National Public Health Insurance Departmentof Negotiations. The costs include treatment as well as individual ex-ercise therapy. The fees are for a consultation from Monday to Fridayfrom 8 a.m. to 4 p.m. Consultation costs are derived according to amodule system in which every module is defined as an independentservice and is estimated to take approximately 15 minutes. A moduleis compensated by the same amount regardless of its content. A con-sultation is made up from 1-6 modules per session and the durationof a consultation will therefore last from 15-90 minutes. During theperiod of treatment in our hypothetical 4-week treatment model weassumed that a patient would consult a physiotherapist a minimum
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of 8 times averaging 3 modules per visit. The cost of each module is60 DKK
Practising ChiropractorThe fee schedule for consulting a chiropractor (1997 figures) has beenprovided by the National Public Health Insurance Department of Negotiations. During the period of treatment in our hypothetical 4-week treatment model we assumed that a patient would consult achiropractor 7 times. Consultations are divided into; 1) chiropracticexamination and treatment, 2) chiropractic treatment, 3) supplemen-tary services and 4) x-ray examination.
Medical SpecialistDuring the period of treatment in our hypothetical 4-week treatmentmodel we assumed that a patient would consult a medical specialist3 times. The given fees are those agreed upon by the National PublicHealth Insurance Department of Negotiations and the Association of Medical Specialists for patients with ordinary public health insu-rance. The fees include a supplement of 12.8% as well as holiday pay.Consultation fees include extra services involved in treatment such asinjections and so forth.
Relaxation TherapistDuring the period of treatment in our hypothetical 4-week treatmentmodel we assumed that a patient would consult a relaxation thera-pist once a week. The fee has been set at 300 DKK per visit.
Medication CostsWe assume that medication treatment will last for a minimum of 4 weeks. Our calculations begin with an inexpensive pain relieving me-dicine in full dose as well as an expensive arthritic medication. The in-expensive medication is paracetamol which we assume will be taken ina daily doses of 4 grams. During the course of treatment approximat-ely 200 tablets will be taken. Costs according to 1996 prices are 1.85DKK per day, if pills are purchased in bottles of 100 pills. This resultsin a total cost of 56.00 DKK for 30 days. The expensive medicine chosen was tiaprofensyre where the daily doses has been set at 2 times300 mg. The price per day will be 6.5 DKK if pills are purchased in bot-tles of 100 pills (1996 prices). Costs related to the expensive medicationduring the 4-week period will therefore amount to 196.00 DKK.
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Diagnostic ImagingTable 1 also includes costs associated with different types of diagno-stic imaging which would be relevant in conjunction with the treat-ment of back patients. X-ray examination of the lumbar spine willusually involve 4 projections. Costs given for imaging examinationsare based upon previously undertaken calculations1 as well as cal-culations carried out at the Hillerød Hospital (MR-scans).
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TABLE 1Costs associated with 4 weeks of treatment for low-back patients in the primary health care sector Number Type of service DKK In total
General practitioner:4 Consultations 96 384
Physiotherapist in private practice:8 Treatments 180 1.440
Chiropractor in private practice:
1 Chiropractic basic examination and treatment 295 295
6 Chiropractic service 147 882
2 Supplementary services 74 148
In total 7, visits at a chiro. in private practice 1.325
Medical specialist:
1 Initial consultation 434 434
1 Additional services 50 50
1 Second consultation 217 217
1 Additional services 50 50
1 Third consultation 106 106
1 Additional services 50 50
In total, 3 consultations at a medical specialist 907
Relaxation therapist:
4 Treatments 300 1.200
Medication:
1 - Inexpensive medication 56 56
1 - Expensive medication 196 196
Diagnostic imaging:
1 - X-ray examination of the spine, chiropractor 377
4 - X-ray examination of the spine, hospital 360 1.440
1 - CT-scan 1.000 1.000
1 - MR-scan 1.000 1.000
1) Anni-Ankjær-Jensen. Cost calculations for the depar tment of radiology in the DSI-repor t 94-04. “Production- and effectiveness measurements in the hospital sector- cost models used in practice”.
TREATMENT IN THE HOSPITAL SECTOR
The following examples of costs associated with hospital treatmentare based upon figures from a particular hospital. Calculations use total average costs because costs involve both direct costs (such asphysician and nurse times, materials, etc.) and indirect costs (utilisa-tion of administration, heat, cleaning, etc.). All calculations are excluding interest and depreciation costs.
MethodWe have used to different methods for our calculations. The “top-down” principle involves a division of the total costs by the total acti-vity in the department in question during the period in question. Thisprinciple is used for calculations related to costs per day for hospita-lised patients.
The “bottom-up” principle involves adding all of the directcosts that are related to a given activity/treatment. This principle isused to calculate costs associated with ambulatory treatment in spinecenters and for cost calculations associated with disc herniation ope-rations including costs related to anaesthesia. This method only ad-dresses the costs, which can be directly related to the given activity.One is left with the indirect costs such as wages during breaks andwaiting time, daily operational expenses, costs related to educationalactivities and new major purchases. If it is desired one can add an am-ount which represents a part of the indirect costs associated with thedepartment. Due to the fact that the total direct costs of the depart-ment cannot be exactly determined, 30% is the number usually used.
The hospital’s costs associated with administration, repairs,water, heat, electricity and so forth represent approximately 32% ofthe costs associated with running the departments in which patientsare treated. We have therefore added a cost to all treatments of 32%,which we have called “overhead”. A more detailed description of thismethod of calculation is provided in appendix C.
Conser vative treatment while hospitalised for 2 weeks or treatment at aspine centerTable 2 includes examples of two alternative treatments in the hospi-tal sector for patients suffering from low-back pain. 1) conservativecare while hospitalised for 2 weeks and 2) ambulatory treatment in aspine centre. The first alternative includes the cost for using a hospi-
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tal bed2 in the department where the patient is hospitalised. In addi-tion, there are costs associated with resources provided by other hospital departments. We assume that during the period of hospitali-sation a plain x-ray as well as a CT scan will be undertaken. The costsassociated with the latter alternative include wages to the personnelthat are involved with the ambulatory care (physician, nurse, phy-siotherapist, secretary and so forth). In addition to material coststhere are the costs associated with x-ray and CT scans. We assumethat treatment at a spine centre involves 4 ambulatory consultations(30 minutes each) as well as one telephone contact in conjunctionwith each consultation.
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TABLE 2Costs associated with 2 weeks of conservative treatment at a hospital andambulatory treatment at a spine center
Alternative I (hospitalisation)Number Cost category DKK In total
14 Days of hospitalisation 1.629 22.806
4 X-rays of the spine 360 1.440
Samlet alternativ I 24.246
alternative II (ambulatory care)Salaries Min. DKK In total
4 ambulatory treatments of < 30 min. duration
1 physician 120 376 752
1 nurse 120 154 308
1 physiotherapist 120 180 360
1 secretary 120 148 296
Other costs such as materials etc. 100 100
4 telephone conversations of < 20 min. duration
physician time 80 376 501
Number Cost category DKK In total
4 X-rays of the spine 360 1.440
In total, alternative II 3.757+30% indirect costs associated with using the department 1.127
2) We refer to appendix B for a more detailed review of the method used to calculate the costs associated with the utili-sation of a hospital bed.
Operation for disc herniationTable 3 illustrates a calculation of the costs associated with hospitali-sation and operation for a disc herniation. The resource utilisationcan be divided into 4 phases: 1) pre-hospitalisation examination, 2) a consultation with an anesthesiologist, 3) the operation and anest-hesia, 4) hospitalisation. Appendix A includes a more detailed reviewof the calculations associated with each of these 4 areas.
COSTS ASSOCIATED WITH REHABILITATION
Table 4 shows 3 alternative methods of rehabilitation a spine. Thefirst alternative is treatment at a “back school”, which takes place ata hospital. The cost was estimated by an expert panel. The second
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TABLE 3Costs associated with a disc herniation operationCost category DKK
Pre-operative examination/CT-scan 1.580
Anesthesia consultation 269
Operation:
Operation department 2.937
Anesthesia department 1.775
7 days of hospitalisation 11.403
Total direct costs 17.964
TABLE 4Costs associated with post-operative rehabilitationCost category DKK In total
Alternative l: (treatment at a back school)
Total cost for alternative I: 2.000 2.000
Alternative II: (treatment at a physiotherapy clinic)
24 training sessions – 28 modules: 60 1.680
Alternative III: (treatment at a chiropractic clinic)
12 basic clinical services: 147 1.764
12 training sessions 74 888
2 supplementary services 74 148
Total costs of alternative III: 2.800
alternative takes place at a physiotherapy clinic, during which the patient receives 28 modules of rehabilitation. The last alternative takes place at a chiropractic clinic. The patient will receive 12 basicservices, 12 training sessions and 2 supplemental basic services.
These appendices (in danish only) can be retrieved by contacting:
Danish Institute for Health Technology AssessmentNational Board of Health13 AmaliegadeP.O. Box 2020DK-1012 CopenhagenDenmark
COSTS ASSOCIATED WITH SICK-LEAVE BENEFITS
In Table 5, the maximum sick-leave benefit that a patient can receiveper week is given. The benefits are based upon the person’s incomeand are calculated according to the hourly wage that the wage earnerwould receive during sick leave minus the amount that would be paidto the work-market contribution fund. It is necessary to know thenumbers of hours as well as the hourly wage during sick leave in order to calculate benefits. Sick-leave benefits are calculated by mul-tiplying the number of hours by the hourly wage. The hourly wageincludes the basic wage plus eventual additional moneys paid forworking at odd hours as well as other personal supplements. Not included are holiday benefits, weekend and holiday pay, pension andsocial security contributions. The maximum hourly wage cannot ex-ceed the maximal total sick-leave benefit divided by the number ofweekly hours that have been agreed upon by the Danish EmployersAssociation and the Labour Unions. In practical terms, one would receive full pay during sick-leave if one’s hourly wage is less that72.65 DKK per hour..
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TABLE 5Sick-leave benefits for 2 weeksNumber of weeks Sick-leave benefits per week In total
2 2.688 5.376Source: Social services 1998: Insurance information, Copenhagen
