Carla Rauseo, PT, DPT, CSCS1,2
1Department of Physical Therapy, Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
2Total Rehabilitation Centre Limited, San Juan, Trinidad & Tobago
Total Rehabilitation Centre Limited
60A Boundary Road Extension
Trinidad and Tobago
Email: [email protected]
Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.
©2021 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association.
Low back pain (LBP) is the leading cause of disability worldwide and was responsible for 60.1 million disability-adjusted life-years in 2015, which was a 54% increase since 1990.1,2 Disability from LBP primarily affects working-aged individuals, which has cross-sectoral financial repercussions, affecting health and social support systems.2 The biggest increase in prevalence has been seen in low-income and middle-income countries.3 While there is little data on the prevalence of LBP in the Caribbean, the region ranked 19th out of 21 regions, with an estimated mean prevalence of 5.67 (CI:5.16-6.26), below the global average of 7.50 (CI:6.75-8.27) in a study on global prevalence.4 However, despite the lower than average prevalence, which may be confounded by data collection challenges, the number of years lived with disability caused by LBP is the third highest compared to all other conditions in the region.4 A study by Hariharan et al5 found that back pain was one of the most common presentations in patients seeking care in public hospitals in Trinidad. Based on this, and data from other middle/low-income countries,3,6 it is likely that the Caribbean faces challenges similar to other nations, with spiralling disability and costs associated with LBP.
Waddell7 argues that there has been no change in the prevalence of LBP. Rather, there has been a steady increase in the disability associated with LBP, and this has led to the massive healthcare costs and problems accompanying the condition. This is evidenced by the high ranking of LBP as the third highest cause of years lived with disability in the Caribbean.4 Waddell7 posits that it is how healthcare has responded to LBP that has changed, and this is what has led to the rise in disability. This change in response by the medical community can be considered as the over-medicalisation of LBP.
Over-medicalisation refers to “too much medicine.”8,9 Over-medicalisation promotes low-value care that is non-concordant with current LBP practice guidelines. This causes considerable harm to patients, excessive healthcare costs and inappropriate use of scarce health resources. Consequently, LBP has been termed an iatrogenic disorder, where exposure to healthcare increases the risk of disability in those with the condition.1,3 Buchbinder et al3 report that there is risk of massive increases in low-value care for LBP in low- and middle-income countries. This viewpoint discusses over-medicalisation of LBP in the context of non-concordance with clinical guidelines, and the barriers to guideline implementation, with particular application to the Caribbean. It also suggests a starting point to improve management in the region.
The guidelines reflect a movement away from medicalised care, and encourage a biopsychosocial approach. For detailed information on the practice guidelines, readers are referred to other referenced works.6,10–12 In summary, after ruling out red flags and assessing psychosocial factors, the guidelines for acute LBP recommend reassurance and advice to stay active, avoidance of bed rest, early return to work and normal activities, and non-steroidal anti-inflammatory drugs (NSAIDs) for short periods. For chronic LBP, exercise therapy and psychosocial interventions, with consideration of antidepressants and NSAIDs are recommended. Referral for imaging is limited to cases only where serious pathology is suspected, and referral to a specialist is recommended if there is no improvement in acute pain after 4-6 weeks, or if specific pathology is suspected.10
Adherence to the guidelines has shown promising results in terms of reducing costs and improving patient outcomes, particularly in the longer term.13–17 Owens et al18 found a significant trend in the relationship between guideline compliance and lower costs associated with claims in work-related LBP.
Despite this, there is a considerable global gap between evidence and practice, with pervasive low-value care which facilitates over-medicalisation.6 For example, a systematic review by Zadro et al19 found that only 54% of physical therapists chose appropriate treatment for musculoskeletal conditions, while 81% chose treatments that had no recommendations in the guidelines. Another recent systematic review by Downie et al,20 noted that the rate of complex imaging has increased over the last 21 years despite guidelines and educational campaigns such as Choosing Wisely. Lemmers et al,21 in yet another systematic review, concluded that imaging may be associated with higher medical costs, increased healthcare utilisation and greater absence from work. Other studies have shown generally sub-optimal compliance behaviour among physiotherapists and physicians.22–24 Buchbinder et al25 reported that physicians with a special interest in LBP have poorer knowledge about how to treat it, which raises worrisome questions about management in the community. Furthermore, the psychosocial aspects of LBP are poorly managed in all income settings.6 This reflects a biomedical approach. To the author’s knowledge, there are no studies available on the management of LBP in the Caribbean. However, based on data from other low-middle income countries,3 it is possible that similar low-value practices exist in the region.
The physician has been termed the “gatekeeper to over-medicalisation,”26 yet faces barriers that facilitate the phenomenon. Slade et al27 reported that the majority of clinicians were unfamiliar with the guidelines. Other providers felt that guidelines restricted their clinical judgement and challenged their professional autonomy. Instead, they relied on past experience, colleagues and protocols of their organisation when managing LBP. Many stated that accepted practice among colleagues superseded the guidelines. In addition, clinicians felt the need to maintain the patient-provider relationship by avoiding patient conflict, and acceded to patient expectations for imaging and a specific biomedical diagnosis.27–31 Providers also cited time constraints as a barrier to implementation, and a reason for ordering frequent magnetic resonance imaging (MRI) scans, as it was easier and faster than taking a comprehensive history and having a discussion with the patient.30,31 This is pertinent to a fee-for-service practice where volume may be prioritized for productivity. The fee-for-service model is common in private practice settings in the Caribbean, and balancing productivity with guideline-concordant care can be challenging for some clinicians. Time constraints may also be problematic in the public sector because of the large volume of patients accessing free care in these universal systems in the region, where organisational structure and policy play a large role in how care is provided.
Other provider-related barriers that facilitate over-medicalisation include false beliefs that imaging will lead to a definitive diagnosis.27 In a systematic review, Sharma et al32 found that clinicians and patients falsely believe that imaging is important for locating the specific source of non-specific LBP, despite the fact that a particular origin cannot be identified in this condition. In addition, the fear of litigation for missing a serious pathology was a significant reason for the use of unnecessary imaging, despite absence of red flags.6,32
Vested interests are a barrier to high-value management of LBP. Shreibati and Baker33 showed a strong positive correlation between physician acquisition of MRI equipment and patients with LBP receiving MRI scans. Other studies34,35 support this phenomenon, and led to the creation and subsequent modifications of the Stark Law36 in the United States to curb increasing healthcare costs resulting from physician self-referral. Furthermore, added imaging for LBP does not improve outcomes and has been associated with increased rates of surgery, increased healthcare costs, and poorer outcomes.33 These vested interests are also applicable to rehabilitation fee-for-service settings where rehabilitation professionals can self-refer for adjunctive treatments in multi-disciplinary practices.
Despite the paucity of research on LBP in the Caribbean, it is likely that the region faces similar challenges to other middle/low-income nations. However, the degree to which these challenges are experienced, seems unknown. We are left to hypothesise about effective strategies for implementation of best practice, which should be specific to the region in order to be successful. Therefore, the first step to reducing over-medicalisation of LBP, should be to understand the problem in the Caribbean by conducting studies aimed at epidemiology, current management of LBP, provider knowledge of guideline-concordant care, barriers and facilitators to best practice and clinical outcomes. Understanding the regional culture/public’s beliefs about LBP should also be investigated, as it has been suggested that acculturation to biomedical approaches to LBP risks increasing disability through over-medicalisation.3
Funding research aimed at the above is vital to addressing the problem of over-medicalisation of LBP. Given the devastating effects of the disability caused by LBP, particularly in working-aged individuals, and subsequent loss of productivity and rising healthcare costs associated with the condition in middle-low income countries,1–3,6 it behoves government agencies and funding bodies to invest in regional LBP research as a critical matter of public health.
At a health policy level, an electronic database that requires all diagnoses and interventions to be logged is absent in Trinidad and Tobago. It is therefore impossible to perform retrospective analyses of diseases and interventions to monitor trends, outcomes and provision of care. One cannot understand an issue if there is no data. Creation of such a database, albeit expensive, will allow valuable research of all health conditions, not only LBP, and can be instrumental in improving public health.
If the disability and costs associated with LBP are to improve, movement away from an iatrogenic medicalised model, and a greater focus on a biopsychosocial, guideline-concordant approach are essential. The barriers that prevent such implementation must be addressed in ways specific to the Caribbean, but more research on the phenomenon of LBP in the region is needed before effective strategies can be created. Funding research on LBP and creating health policy that mandates electronic documentation of disease in the public and private sectors are necessary steps to improve understanding and curb over-medicalisation of this exigent crisis.
Acknowledgements: Dr. Chanol Ottley, DPT, CKTP
Competing Interests: None
Ethical Approval: Not applicable
Funding: Not applicable
Author Contributions: Carla Rauseo developed and wrote the manuscript.
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