BACK PAIN – A GLOBAL CRISIS
Back pain seems so universal nowadays, we can almost forget that it is something that affects many of our lives on a daily basis. Spanning all variations and intensities, back pain can range from a mild discomfort to a full immobilising and debilitating state that requires immediate medical care. It is also the leading cause of disability in most countries and across all age groups, with over half a billion people affected worldwide (Hurwitz et al., 2018). Given the ageing population in most countries, and the increase in sedentary behaviour, this trend is likely to only worsen in the years to come.
In the U.S., back pain is the 6th most expensive condition, which accounts for the most lost work days. In 2005, approximately 33 million American adults reportedly suffered from back and neck problems, resulting in absence from the workplace (Chandwani, 2013).
While most cases of back pain resolve within six weeks, up to a quarter of cases lead to chronic conditions that can have a profound effect on one’s daily life, and a significant chance of negatively affecting a person’s mental and emotional health.
Chronic back pain also has huge economic ramifications, with only half of individuals whose disability persists for over six months returning to work (Anderssen, 1999).
It is hard to put a price tag on this, but a study from the U.S. came up with a scary estimation, which illustrates the socioeconomic catastrophe we find ourselves in today. For a two-year period during 2008-2010, the total national costs related to all causes of chronic back pain amounted to an estimated $187 billion, including both direct medical costs and indirect costs, such as that from lost labour. Per person, this worked out to $37,129 in direct medical costs, including $19,849 for prescription medications (Chandwani, 2013). Outside of the United States, the situation is no less dire, as a study that assessed the direct and indirect costs of low back pain in Australia, Belgium, Japan, Korea, the Netherlands, Sweden and the U.K. between 1997 and 2007 concluded that back pain represents a “substantial burden on society” (Dagenais et al., 2008).
Chronic back pain not only has a major impact on a person’s ability to show up for work, it also affects productivity while in the office. In one U.S. study, common pain conditions – which attributed to reduced performance but not workplace absence – resulted in a mean average loss of 5.2 hours of productivity per week (Stewart et al., 2003). When we consider just how many people suffer from chronic back pain, we can only imagine just how many productive hours are lost that go unaccounted for.
Professions that require a large amount of sedentary work time, such as vehicle drivers and office workers, are often at the greatest risk for chronic back injuries. An Israeli study looking at 384 male full-time urban bus drivers found that almost every other driver had experienced lower back pain in the past 12 months (Alperovitch-Najenson et al., 2010). Other studies that looked at over 2,500 office workers, have found that between 33% and 50% of participants had experienced back pain within the last year (Ranasinghe et al., 2011, Celik et al., 2018). These numbers likely don’t even sound all that surprising, given what we know from our own experiences in the workplace.
HOW BACK PAIN IS MAKING US MENTALLY SICK
Chronic back and neck pain also take a significant toll on our mental health and wellbeing, and can lead to ‘disuse syndrome.’ This term, coined in the 1980s, encapsulates the idea that chronic pain conditions act as a downward spiral, leading to more sedentary behaviour and, as a result, a continual decline in both physical and mental capabilities. The concept of ‘use it or lose it’ means that chronic back and neck pain can adversely affect a person’s social and professional interactions, their sexual health, self-image and self-confidence, recreational activities, parenting or caretaking capacity, and their ability to perform everyday tasks related to personal hygiene, cooking, cleaning and overall quality of life.
These restrictions go on to increase a person’s vulnerability to malnutrition and infection. In fact, chronic lower back pain has even been associated with a host of deficits in cognitive function, including impairment of information processing speed and working memory (Schiltenwolf et al., 2017).
With this laundry list of associated ailments, it is no surprise that we also see a high correlation between back pain and depression. A Korean study looking at health records for 7,550 people found that, in general, people with lower back pain were nearly four times more likely to be depressed. Respectively, people with severe depression had an increased risk of lower back pain by nine fold!
This certainly represents something of a chicken-egg scenario. A person who is depressed may have a greater sensitivity to pain and may be less physically active and engaged in other healthy behaviours, while somebody with back pain may also have the same difficulties engaging in regular exercise, particularly if they are suffering from sleep problems and are experiencing social and professional isolation and dissatisfaction, all potentially contributing to depression (Alhowimel et al., 2018). Regardless of whether someone initially suffers from depression or back pain, it can lead to a vicious cycle that can be difficult to get out of.
OPIOIDS: A SHORT-TERM SOLUTION FOR A LONG-TERM PROBLEM
Patients consulting their physician often favour immediate relief, particularly when they know that physicians have a miraculous tool in their arsenal which promises just that – opioids. As Maslow is famously quoted in the law of the instrument, “If all you have is a hammer, everything looks like a nail.” This leads us to today: a quick fix that makes patients happy usually results in them coming back for more, but never actually solves the underlying issue.
The rates of prescription opioids for back pain in the United States has skyrocketed, reaching endemic proportions to the point that it has been called a public health emergency. Compared to most European countries, rates of opioid prescriptions are two to three times higher in the U.S. and Canada (Deyo et al., 2015).
Long-term use of opioids can lead to various side effects. With a vicious cycle of increased drug tolerance, harrowing withdrawals, and greater sensitivity to pain (hyperalgesia), addiction sets in with higher risk of overdose and even death. Other issues related to opioid use include the risk of falls and fractures, as well as depression (Deyo et al., 2015).
Given the risks associated with opioid use, one would assume that there must be significant benefits to prescribing these medications for pain management. However, this is not supported by research, as workers who are prescribed opioids for acute back pain do not return to work more quickly, nor do they have improvements in functional outcomes with opioid use. In fact, there is very little research indicating any real benefit to long-term opioid use in the effective management of back pain (Deyo et al., 2015).
About the Author
Eric Soehngen, M.D., Ph.D. is a German physician and specialist in Internal Medicine. With his company Walkolution, he battles the negative health effects that sitting has on the human body. Walkolution develops ergonomically optimized treadmill desks, which help to bring more movement into the daily work routine in the office or home office.
Photo credit: Joyce McCown