This action might not be possible to undo. Are you sure you want to continue?
Frequency, Management and Prevention from an HTA perspective
Danish Institute for
Health Technology Assessment
D I H T A
Frequency, Management and Prevention from an HTA perspective
Danish Institute for
Health Technology Assessment
D I H T A
Frequency, Management and Prevention from 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
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
Printed witout solvents, using only natural vegetable colours, on environmentally approved paper.
it is today acknowledged that the individual diagnosis and treatment offered to patients with low-back pain. The report consists of to volumes. One important strategy element is: “Denmark will ensure. that the multidisciplinary working group was able to agree both on a proposal for clinical guidelines for diagnosing patients suffering from low-back pain and recommendations on a number of different treatments and prevention. is very varied. where volume 1 is a survey of the extent of the problem in Denmark. representing relevant professions in the Health Care sector. and treat-ment should. be individualised.Foreword Low-back pain is one of the most frequent reasons for contact with the health care system. The report was made by a multidisciplinary working group. 3 . This variation is not always and only an expression of the fact that diagnostic and treatment are adapted to the individual patient. that the report will be well received and used by the different professions responsible for treatment as well as by the authorities with the managerial and economic responsibility for the health service in Denmark. It is DIHTA’s hope. the Health Technology Assessment Committee of the Danish National Board of Health published “The National Strategy for Health Technology Assessment”. and volume 2 is an evidence-based evaluation of different treatment methods and evidence-based recommendations for prevention diagnostics and treatment. therefore.” The background of the present report is to adapt international health technology assessments (HTA) into Danish conditions. In 1996. Low-back pain includes different conditions. that international HTA initiatives are monitored and the results applied to the Danish National Health Service. However. DIHTA ﬁnds it of great value. On this background a number of national and international research projects have been made using a Health Technology Assessment (HTA) approach with the perspective to manifest today’s knowledge on the problem and the most rational way to handle it.
Statens Institut for Medicinsk Teknologivurdering Januar 1999 Finn Børlum Kristensen 4 .
. . . . . . . . . . . . . . . 16 The prevalence of low-back pain in Denmark . . . . . . . . . . . . . . . . . . . . . . . 42 7. . . . . . . . . . . . . . . . . . . . . . . . . 44 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Established causes of low-back pain . . . 26 Diagnostics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Acute low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Foreword . . . . . . . . . . . . . . . . . 43 Increased inter-disciplinary co-operation . . . . . . 43 Individual patient information . . . 34 Imaging (X-ray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Suggestions for the future organisation of low-back pain assessment and treatment . . . . . . . 35 6. . . . . . . . . . . . . . . . . . 34 Bloodtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 The present health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Waiting times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What is “low-back” pain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 The clinical examination . . . . . . . . . . 10 VOLUME 1 1. . . . . . . . . . 19 2. . . . . . . . 15 Deﬁnition . . . 3. . . . . . . i-iv Members of the panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Health Technology Assessment and sources/references . . . . . . . 4. . . . . . . . . . . 29 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Risk factors (indicators) . . . . . . . . . . . . . . .Contents DITHA’s summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How do we address the low-back problem from an organisational standpoint? . . . . . . . . . . . . . . . . . . CT and MRI-scans) and spine diagnosis . . . . . . . . . . . Illness Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Incidence of low-back pain in the historical perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Chronic low-back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Social and Economic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and suggested areas of focus. . . . . . . . 8 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. . . . . . . . . . . . .
. . . . . . . 61 The hta-evaluated treatments . . . . . . . . . . . . . . . . . . . . 73 Injections in the muscles. . . . . . . . . . . . . 45 Quality control: databases & reference programs . . . . . . . . . . . . . . 60 Treatment strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Teaching/research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Increased knowledge of the course of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . joints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Public information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Back surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Manual therapy. . . . . The LPB-group’s analytical method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment methods that can be recommended in certain conditions . 81 Bed rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Costs that are associated with the utilisation of the technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . muscles and ligaments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Massage and heat/cold therapy . . . . . . . . . . . . . . . . . . . . . including acupuncture. . . . . . . 58 The panel’s recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . 55 HTA-blueprint . 65 Pain relieving medication . . . . . . . . . . . . . . . . 74 Facet and sacroiliac joint injections . . . . . . . . . . . . . 55 The panel’s evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Stabilising back surgeries . . . . . . . . . . . . . . . . . . The various Danish health professions that treat patients with “low-back pain” . . . . . . . . . . . . . . . . . . . 73 injections in trigger points. . . . . . . . . . . 45 Hospitalisation/amubulatory treatment/multi-disciplinary teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatments which can generally be recommended . . . . . . . . . 60 Active or passive treatment. . . . . . . . . . . . . . . . . . 57 Grading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Patient information . . . . . . . . . . 45 X-ray examination of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Exercise therapy/ﬁtness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Spinal stenosis. . . . . . . . . . . . . . . . . . 48 VOLUME 2 1. . . . . . . . . . . . . . . . . . . . . . . 58 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Co-operation between health care providers . . . . . . . . . . . . . . 67 Exercise therapy according to mckenzie . . 82 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Back school/group training/ergonomics . and ligaments and in close approximation to nerves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Documented treatment effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Epidural injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 5. . . . 47 The overall co-ordination of efforts/professional fee schedules . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 100 7 . . . . . . . . . . . . . short-wave therapy . . . . . . 92 Costs of the singular activity . . . . . . . . 83 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Costs . . . . . . . . . . . . . . . . . . . . . . . Economics. . . . . . . . 85 Ultra sound. . . . . . . 99 Appendix. . . . . . 91 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Corsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Secondary/tertiary prophylaxis . . . . . . . . . . . 92 Box economic analysis of a course of treatment for “low-back pain” . . . . . . . . . . . Treatments that cannot be recommended . . . . . . . . . . .Transcutaneous nerve stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Traction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 How can these savings be achieved . . . . . . . 90 Social assistance programs . . . . . . . . . . . . 93 Savings if “recommended treatment courses” are carried out . . . . . . . . . . . . . . . . . . . . . . . . . . 86 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . laser. . . . . . . . . . . . . 88 Primary prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Concluding comments.
DIHTA’s summary and conclusions .
in order to improve a better decision making in the health care system. Based on scientiﬁc documentation the statements regarding the technology was evaluated on a 4-step scale. The past ten years’ science has clearly shown that a patient activating treatment strategy. O RGANISATION Interdisciplinary agreements exist among the experts upon the following general principles on the organisation of care in the low-back pain area: i . into Danish conditions. both for the acute and the chronic lowback pain patient is of great importance to ensure a stable effect of the treat-ment. M ETHODS A broadly composed working group of relevant professionals made this report as a result of a systematic consensus process based on a thorough evaluation of published scientiﬁc evidence and clinical expertise. it forms the basis for preparation of the most suitable programme of examination. The main purpose of the clinical examination is to make a speciﬁc diagnosis and to exclude the existence of serious back diseases. already published on diagnosis. For a successful treatment result a motivated participation chosen by the patient is important. In addition. the group suggested a recommendation/nonrecommendation of future use of the individual technology. Explanations are linked to each recommendation.and treatment for the patient concerned. treatment and prevention of low-back pain. so it is clear under which circumstances the recommendation is valid. T ECHNOLOGY A thorough examination carried out at the very ﬁrst visit is the most important activity in the handling of the low-back pain patient.I NTRODUCTION The purpose of this HTA is to adjust international technology assessments. Based on estimates a graduation in three degrees was made of the expected economic consumption of resources that the use of each single technology would release. Furthermore. In the ﬁrst place the quality of the scientiﬁc basis of using each individual technology was assessed – carefully guided by equivalent foreign HTA-reports.
if possible. for exchange of notes from case records (after permission from the patient is obtained). All treatment should. irrespective if the patient consults his or hers general practitioner or chiropractor. Hospitalisation of patients with low-back pain is not recommended. treatment results etc.Irrespective of how the patient chooses to contact the health care system. Hospitalisation causes unnecessary labelling of the patient and often also a feeling of inactivity and loss of self-determination. which derives from professions’ – by authorisation – deﬁned business areas. Normally. x-rays. The formal and informal routes of referrals should in general be kept unchanged. take place in the primary sector and in the patient’s own area. This prevents or minimises the occurrence of multiple parallel episodes of care. If serious back disease occurs e. During the treatment course a close co-operation is important among the relevant professionals in primary care.g. Referral to specialist care or to a specialist centre should generally not occur before other relevant diagnosis/treatment in the primary sector has been tried. This is important in order to avoid unnecessary labelling of the patient and to avoid needless costs for the patient and/or to the health care system. In suspicion of bone fracture after trauma the patient is recommended to contact the emergency services. patients with acute low-back pains are recommended not to consult emergency wards. as for example long transports. It should be ensured that the content of the individual treatment course is homogenous. as most of the emergency wards are unable to carry out a thorough evaluation of the problem. bad pains. hospitalisation will often be necessary. Similarity in information ii . Referral to specialist care or a specialist centre is recommended at once if alarming symptoms of back disease appear or if the patient does not recover within 4 weeks in spite of regular treatment in the primary sector. Individual patient information during the diagnosis-/treatment efforts should always be a key activity. it is important that examination and treatment procedures are the same. The organisation of care should enable a division of work.
given to the patient should be ensured. especially the social authorities. The working group was not asked to deal with future division of work between the caregivers. Economic aspects inﬂuence practice behaviour. In crucial areas implementation of the results of the report should go through interdisciplinary formed reference programmes and clinical guidelines. will also bring about savings of public costs in areas such as transfer payments (sickness beneﬁts and pensions).and treatment procedures are carried out. should be worked out. reumatologists. In addition reference programmes describing in which cases blood tests are necessary. a range of treatments will deﬁnitively disappear from the health care system’s handling of low-back pain. and changes in collective agreements and contracts may cause great effect. E CONOMY Implementation of improved care programmes.g. (local. Broad implementation strategies that form a combination of printed material. audit-feed back of actual treatment activity and visit by colleagues to the clinic is best suited in order to obtain changes in clinical behaviour. which could be made through discussions and negotiations with public agreement parties such as Sygesikringens Forhandlingsudvalg (The Board of Public Health Insurance). collegiate inﬂuence from opinion leaders. however. informs and advises the patient. irrespective of the kind of practitioner that evaluates. To obtain the best possible communication and co-ordination between professionals involved and with other parties e. carried out in co-operation with radiologists. One obvious subject could be a reference programme with guidelines for the work out of “correct x-ray procedures”of the low back. besides causing savings at the budget in the health care system. and more effective patient episodes of care will represent far a bigger fraction of cases. Overall factors in obtaining savings are: ❖ ❖ ❖ To avoid costly waiting time. There is. a need for such a clariﬁcation. DIHTA’ S CONCLUSIONS If the documentation and recommendations of this report are followed. surgeons. iii . To avoid that unnecessary or needless diagnosis. small-group based) problem oriented education. general practitioners etc. chiropractors.
A strengthened individual information effort towards the patient – both in the primary-and in the secondary sector – is an important aspect for the strengthening of future efforts. which are willing to undertake education of scientists and methodology advisers. The professional groups’ thorough work has revealed a big need for a broad scientiﬁc effort in the ﬁeld of clinical science research and health services research. the low-back pain-report must be updated after four years at the latest. Particular courses for social-/rehabilitation staff should be given higher priority than it is in the care today. Individual information is recommended and should be based on the individual situation and need. Common and improved training of physicians. Thus. therefore. Methodological competence at high levels is necessary for valid and reliable results. Information about the problem and treatment is most often repeated several times before the patient gets full insight into the matter. The newest welldocumented professional know how should also form the basis for decisions about social measures for patients with low-back problems. chiropractors and physiotherapists should be developed so the professions get a more equal approach to the individual patient and a technical language that is more common than it is today. Relevant professional academic environments should support the training. The collective agreements’ possibility to promote this information effort should be analysed critically. These courses should also include other relevant professional groups such as teachers of relaxation and psychologists.It is important that the patient early in the treatment course takes an active part by receiving a thorough information. A shared patient record and electronic communication should be developed and tested so that the practitioners can share information about diagnosis and treatment already carried out. a need for supporting academic centres. in order to preserve its relevance. The evidence basis for decisions on treatment is regularly changed. There is. iv .
MD Danish Rheumatological Society Niels-Frederik Pedersen. MD Danish Society for Musculoskeletal Medicine Professor. 8 . MD Danish Society of General Medicine Chief Physician Svend Lings. and C. Chief Physician Hans Christian Thyregod. has participated in the production of the Appendix and Appendices A. DC Danish Chiropractors Association Chief Physician Claus Mosdal. Physiotherapist Kirsten Williams Danish Physiotherapy Aassociation Chief Physician Finn Biering-Sørensen. Chief Physician Tom Bendix. MD Danish Society for Occupational and Environmental Medicine Chief Physician Lars Remvig. MD Danish Society of Neurosurgeons Hospital Director.Members of the panel This manuscript is the result of work carried out by a panel which was appointed by the Health Technology Assessment Committee of The Danish National Board of Health. University of Odense. of the Center for Health Services Research and Social Politics. MD Danish Society of Orthopaedic Surgery Chief Physician Erik Martin Jensen. MD Kim Upperup. (Chairman)* Economic Affairs Anni Ankjær-Jensen* Assistant manager Anni Olsen* Relaxation Therapist Anni Fog Danish Relaxation Therapists. Chief Physician Claus Manniche MD. MD The Arthritis Association * Members appointed by the Health Technology Assessment Committee of The Danish National Board of Health. Protocol records: Per Bülow. Professor.B. MD Danish Epidemiologic Society Peter Kryger-Baggesen. The manuscript was compiled by Claus Manniche.
whereupon it was published by the National Board of Health. The LBP9 .a delineation of the problem. Low-back pain has such a high prevalence in the general population that an episode should almost be classiﬁed as a normal occurrence. health professional organisations as well as their members in the Danish health care sector. prevalence and suggestions for its management” to the committee. The LBP-group continued its work until the present report was completed after holding 31 meetings until August 1998. and the responsibility for concluding the work was placed here. The task of the LBP-group was to adapt published international HTA reports regarding the diagnosis. treatment and prevention of “lowback pain” to Danish conditions. The ﬁrst volume was published in 8000 copies. This result in a great utilisation of treatment. The scientiﬁc societies from different medical specialties that are involved with the examination and treatment of low-back pain each appointed a representative to the LBP-group. This report has been sent out to those responsible for political decisions. The LBP-group was comprised of individuals representing the different professional associations that deal with low-back pain and also included a representative from a musculoskeletal patient association. In the fall of 1996 the LBP-group delivered the report entitled “Low-back pain. Individuals with expertise in administrative and economical affairs related to the hospital sector were also included. In 1997 the Danish Institute for Health Technology Assessment was formed. The LBP-group has carried out its work in an objective manner and has demonstrated a willingness to look closely at the entire area under investigation without political interference. sick-leave.Introduction F OREWORD In the spring of 1995 the Health Technology Assessment Committee of The Danish National Board of Health (HTA) appointed a working group which was called the “Low-back pain group” (LBP-group). Every ﬁfth Dane will experience low-back pain during a fourteen-day period. and in many cases health related disability pensions. In this manuscript the initial report will be termed Low-back pain Volume 1.
S. Alf Nachemson. There has been some divergence of opinion as regards a few minor details. The LBP-group has attempted to write a report that can inspire both politicians and professional decision-makers that are associated with the health care sector. Musculo and Skeletal disease in Denmark. pp 1 – 122. 1994. Danish Institute for ❖ ❖ 10 . report nr. ❖ Back pain. With the publication of this report. the LBP-group’s work assignment according to the original commission is completed. The different treatments have been graded according to scientiﬁc documentation so that the reasoning behind their recommendations is clear. Stockholm 1992. Acute low back problems in adults Agency for Health Care Policy and Research.group has reached agreement on all important issues.causes. Volume 1. Technology refers to any method used in arriving at a diagnosis. Statens Beredning för Utvärdering (SBU). HTA includes an evaluation of a series of elements which can be classiﬁed into the following 4 headings: Technology (treatment method). This publication was a thorough review of the entire subject including the documentation of different treatments as well as future strategies. systematic evaluation of the indications and consequences of utilising medical technology. Rockville. The report is written without the use of too many professionals’ terms. as was the case with Low-back Pain. The patient Organisation and Economic 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 for its recommendations. Public Health Service. diagnosis and treatment (pages 1-122). H EALTH T ECHNOLOGY A SSESSMENT AND SOURCE MATERIAL Health Technology Assessment is a thorough. U. 108. This project included a thorough and systematic review of the available literature regarding treatment. The report has been published in a user-friendly fashion and can be used as a reference text. treatment or prevention.
11 . The epidemiological review is particularly thorough. Royal College of General Practitioners. This report is a concise and systematic review of the subject. ❖ ❖ ❖ If another source has been used this will be referred to in the text. Van Tulder MW et at. The Danish Society of Internal Medicine. ❖ Report on Back Pain. Spine 1997.18:2128-56. Figures and Tables are always given with references. The survey is based on interviews with 4818 danes between September 1990 and May 1991. The Clinical Standards Advisory Group. The report includes practical guidelines based upon the “Report of back pain”. Organisations contributing to this report included: general practitioners. 1995. Ugeskrift for Læger. see above. The report is a population based survey of the frequency of musculo and skeletal diseases in Denmark.1996:suppl 4. This “evidence based” medical evaluation of the most commonly used treatment forms for low-back pain was written by a research team from the University of Amsterdam. Conservative treatment of acute and chronic non-speciﬁc lowback pain. physiotherapists and chiropractors. 1-47. 1994. The emphasis was on diagnosis and treatment of the most common acute and chronic low back diseases Clinical guidelines for the management of acute low-back pain. Consensus report: Low back pain. 1-18. As far as was possible reference material representative of the adult Danish population was used. pp. London 1996.Clinical Epidemiology (DICE). pages 135. London.
Low-Back Pain Volume 1 13 .
1987. crooked or curved spine. sciatica. “low-back pain” is deﬁned as tiredness. Anatomically the low back is to be considered the area from the lowest rib and downward to the bottom of the sitting muscles as illustrated in Figure 1. The British report only recognises symptoms of more than 24 hours duration. facet syndrome. muscle tension. degenerative arthritis. Diagnoses commonly used in clinical practice include: lumbago. All symptoms lasting more than three months are considered as chronic symptoms. or pain in the low back region. These “diagnoses” may cover a speciﬁc condition (osteoporosis or disc herniation) but for the most they cover a range of symptoms. The term acute symptom is to be understood as symptoms lasting less than three months. The deﬁnition does not take into consideration either the duration or the degree of symptoms. and so forth. In the remainder of this text these symptoms will be referred to as low-back pain. This deﬁnition does not differ markedly from those used in other international HTA-reports. discomfort. The report includes data on people with low-back symptoms of shorter or longer duration. disc herniation.1 What is “low-back pain”? D EFINITION In this report. 15 . FIGURE 1 The upper region of the low-back The lower region of the low-back Kilde: Standardised Nordic questionnaires for the analysis of muscoloskeletal symptoms. with or without radiating symptoms to the leg or legs. osteoporosis.
the discs. 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. Prior to this time low-back pain was never seen in association to an injured spine. and nerve irritation and low-back pain was unknown. Due to the difﬁculty in establishing a physical cause many of the symptoms were considered to be of an hysterical (psychological) nature. This term is difﬁcult to limit in terms of time and has no particular diagnostic or treatment relevance. Low-back pain was not treated with bed rest in earlier times. In the 20th century it was quickly established that the nervous system could be involved in the development of low-back pain and later on it was widely accepted that low-back pain was possibly caused by an “irritation” of the nervous system. Current knowledge dictates that it is both wrong and clinically ineffective to treat almost all low-back ailments with bed rest of up to several weeks’ duration. As regards low-back pain. the relationship between fractures and deformities had been known for a long time. The use of bed rest was not based upon scientiﬁc documentation but rather on empirical evidence (experience). Research activity in this ﬁeld increased markedly but it was still not possible to establish a direct cause and effect relationship. The most commonly held belief was that symptoms were a result of an irritated nervous system and research focused on this area. Prior to the 19th century the possible relationship between the facet joints.BACK PAIN IN THE HISTORICAL PERSPECTIVE Discomfort and pain in the low-back was ﬁrst described on paper in 1500 BC by Edwin Smith’s papyrus writings.In accordance with the international HTA-reports we do not use the term sub-acute symptoms in this report. This 16 . During this time. I NCIDENCE OF LOW . but was considered to be a valid treatment in this period as symptoms appeared to improve in many patients. The term “wear and tear of the back” became accepted and individuals were entitled to compensation in some instances. the medical speciality orthopaedic surgery was developed. In conjunction with the development of the British railway system (1800-1850) a relationship between heavy work and damage to the back was acknowledged. However. bed rest was the most commonly prescribed treatment.
Many patients became worse off due to bed rest than they would have been otherwise. The tendency to overutilise a newly developed treatment modality for a period of time has also been seen in other areas of medical science. thirty-ﬁve per cent of the population will report that they have experienced low-back pain (either short-lived or persistent) during the past year while twentyone per cent will have experienced back pain during the past fourteen days (Table1). In all likelihood this is due to osteoporosis which is commonly observed in females of this age group.groundbreaking new knowledge regarding the pathoanatomical relationships of spinal structures unfortunately led many physicians to believe that all spinal problems were discal in origin. In spite of these measures the incidence of low-back episodes at the work place continues to rise. As far as age in concerned there is a weak increase in frequency from ages 16 to 67 whereupon a decrease in frequency takes place for both genders. These and other factors may have led patients with ordinary low-back pain on a journey ending with severe disabilities. Many were therefore of the opinion that surgery would be the answer for most back ailments. As great advances were being made in anaesthetics and surgical specialities during this period many low-back pain patients underwent surgery. T HE PREVALENCE OF LOW . Additionally. which includes socio-economic factors as well as work conditions. many of them up to several times. many patients underwent surgery in spite of uncertain pathoanatomical ﬁndings. but the decrease is not as great for females.BACK PAIN IN DENMARK Low-back pain is among the most common painful conditions in the Danish population. 17 . During the past 30 years much energy has been focused upon reducing workloads as a result of the increased number of low-back pain episodes occurring at the work place. which also resulted in physical de-conditioning. Females report a greater frequency of low-back pain than males however the percentage of disc herniations and long-term low-back disability is very similar for both genders. Many preventative measures have been undertaken in order to prevent repetitive work and heavy lifting at the workplace. This development underscores the multi-factorial nature of low-back pain. If questioned directly. The use of long-term bed rest resulted in increased illness behaviour for low-back patients.
BACK PAIN In this section “causes” should be considered as objective ﬁndings such as. DIKE 1991. which can contribute to or cause low-back pain but even after a thorough examination it is not possible to make an accurate diagnosis in 7080% of patients. In the remaining 20-30% a diagnosis can be made on the basis of objective ﬁndings which cannot be found in healthy 18 . We are aware of a wide variety of diseases/conditions.Disc herniation during the past year .Back pain during the past 14 days *) . The newest data from Denmark also point to a further increase compared to the data used in this manuscript.Daily back pain during the past year *) . while pain in the upper spine or both the upper and lower regions of the spine are not as common (Table 2). Factors such as heavy lifting or repetitive work (external factors) are not considered even though they may inﬂuence low-back symptom development. Ref.TABLE 1 Percentage of males and females with various low-back problems in different age groups Males 16-24 Percent with: .Long-term disease # of interviewed people 34 27 2 12 9 3 378 42 36 6 19 1 15 7 923 40 35 11 21 3 19 11 693 24 22 11 16 1 9 7 311 38 33 8 18 2 15 8 2305 41 34 6 18 11 4 388 42 36 8 21 1 11 5 947 45 41 15 26 3 21 15 738 37 34 20 27 3 16 9 440 42 37 12 23 2 15 8 2513 40 35 10 21 2 15 8 4818 25-44 45-66 67+ Total Females 16-24 25-44 45-66 67+ Total M+F *) Back pain in this row is to be considered as both upper and/or lower back pain but not neck pain. x-ray ﬁndings and blood tests which may explain the symptoms. The most frequently reported painful region of the spine is the low-back (28%).Back pain within the past year *) .Other back diseases during the past year . There is no difference between genders as far as spinal pain localisation is concerned (Table 2.) E STABLISHED CAUSES OF LOW . The British “Report of back pain” documents that the number of sick-leave days due to low-back pain has increased three-fold during the past ﬁfteen years.Low-back pain during the past year .
long-term. TABLE 3 The relative contributions (percentages) of various diseases that result in activity decreases. individuals. and disability pensions Activity limitations . Back disease represents approximately 50% of all musculoskeletal disease. 19 . S OCIAL AND ECONOMIC FACTORS There are no speciﬁc data regarding the inﬂuence of social and economic factors and low-back pain for the individual but musculoskeletal disease is the most common cause of decreased daily activity. There is however an element of uncertainty with this latter group as well. Ref. Degenerative changes in the spine as seen on plain x-rays should be considered as a part of the natural ageing process. change of work or loss of work. DIKE 1991. Ref.short-termjob change/ loss -job change-job loss health related disability pension Musculoskeletal disease Heart/vascular disease Nervous system disease Respiratory disease Injuries Psychological illness Other diseases 38 6 5 20 10 2 19 47 9 6 9 7 2 19 21 1 4 39 14 1 21 45 9 6 5 8 7 20 47 5 5 5 10 6 22 43 13 8 5 5 8 7 33 14 11 5 6 8 22 The numbers are given as percentages of all disease groups.TABLE 2 The percentage of males and females with back pain during the previous year Males 16-24 Pain only in the upper region of the back Pain only in the lower region of the back Pain in both the upper and lower regions of the spine No spinal pain 8 23 4 66 25-44 6 33 6 55 45-66 4 30 6 61 67+ 2 17 4 77 Total 5 28 5 61 Females 16-24 7 28 9 57 25-44 7 29 6 58 45-66 5 30 10 14 67+ 3 24 9 63 Total 6 28 8 58 M+F 5 28 7 59 Back pain in this Table is either pain in the lower and/or upper back but not the neck. It has been demonstrated scientiﬁcally (CT-scanning) for example. DIKE 1991. Approximately ﬁfty per cent of all people over ﬁfty years of age have degenerative changes but the incidence of low-back pain is equivalent in people either with or without spinal degeneration. that between 25% and 75% of healthy individuals have positive ﬁndings suggestive of disc herniations. sick-leave and disability pensions (Table 3).
This number equals the yearly hospital day capacity of one of the largest hospitals in Denmark. because many patients are unable to work for differing periods of time due to several competing diseases which 20 . what type of treatment. For example. osteoarthritis as well as other related illnesses was calculated to be 330. It is also difﬁcult to calculate the exact public costs associated with sick-leave and disability pensions directly related to low-back disease alone. which diagnoses?). services provided in the primary health care sector are not registered systematically (how many patients. In Denmark. The number of hospital days used for back illness has remained fairly constant from 1983 to 1993 in spite of the fact that it has been shown that hospitalisation for most back conditions has been shown to be unnecessary or even contributory regarding the promotion of illness behaviour. In addition to this. Similar data can be found from other Western countries which we normally compare ourselves. At present there are no separate numbers as regards costs regarding low-back pain patients as opposed to the overall group of musculoskeltal patients. Ministry of Health 1995 The lower back is the most frequent problem area of the entire musculoskeletal system. Diagnosis Lumbar disc herniation Degeneration of discs or bones in the low-back Low-back pain without signs of disc herniation Discharged ÷ operation 4778 1682 2696 # of days at hospital ÷ operation 43566 16938 25319 Discharged + operation 2880 498 # of days at hospital + operation 26828 5709 Reference: National patient registry. According to the Ministry of Health’s ﬁgures from 1993 the total number of hospital days due to somatic disease in Denmark was 7.5 million. disc herniation.000 hospital days as a result of disc and other vertebral lesions were documented (Table 4). The possibility of arriving at precise public health costs associated with low-back disease is made difﬁcult by the fact that certain disease costs are not classiﬁed singularly. more than 120. and as such we can use the data from the entire group. or referred pain from other organs. The group including spinal disease.000 days per year.TABEL 4 Number of hospitalisation days for chosen diagnoses in Denmark 1994. a large patient group exists with more diffuse symptoms such as osteoporosis.
1 4.3 85. and the usage of medicine outside of the hospital sector. disease specific costs in relation to total column costs. in other words.6 72.865 37.127 12.9 2.0 1.595 3 5. In other words.1 953 3.529 4.eyes.457 3 1. in other words. disease distribution is the average of 1989-91. 1995.182 11.167 5.310 1.7 0 1.4 2.078 26.3 20.130 17.9 24.9 23.079 4.TABLE 5 Social costs for 13 diseases in Denmark calculated according to the cost-of – illness method.4 14.2 1.971 26. which is not included under injuries/accidents or under psychiatric diseases.538 4. costs related to handicap dwellings and other social costs are not included 2) The present value of production loss. 5) Row percentages.5 4.798 2.8 100 578 3.3 634 281 91 432 5.249 503 736 4. Figures are presented as millions of DKK (1992 price index). specialist practices.933 680 2.87 1.3 485 3.5 11. Direct costs1) Costs Pension7) Death Total Total s%4) r%5) s%4) Rank Hospital Primary3) Total s%4) r%5) Sick-leaver6) Indirect costs2) Disease Musculoskeletal disease 3.145 2.891 112 18.224 22.866 3944 10.535 2.5 66.762 7.324 3.1 28.8 81.111 242 935 2.339 2. the disease distribution is from 1981 7) Permanently reduced ability to work or total loss of ability to work.354 4.3 212 860 605 1.439 17.660 11.820 2.350 9.9 63.5 40.843 4.2 14.5 847 2.1 1.067 2.7 1. 1284.273 16.0 1. The diagnostic classification is the one used in 1989 4) Column percentages.096 15.265 668 1.9 1.2 4.9 8.6 0.257 29. 21 .433 102.0 76.9 73. Costs include both public health insurance costs as well as the direct costs paid by the individual patients.446 924 924 693 4.3 59.686 400 1.848 924 3.9 1.143 8.142 1.006 1.068 6.7 1.295 3.915 140.ears Diseases of the urinary tract and reproductive organs Infectious diseases Heart and vascular disease Diseases related to pregnancy Other diseases8) Total 1) BTreatment costs included only resources used in the health care sector as defined in Denmark. physiotherapeutic treatment.122 540 24.528 6.021 8.234 1.7 21.7 66.1 60.719 9.105 55.8 18.848 1.236 4.7 61.8 33.5 100 2 4 7 5 8 10 1 9 12 13 3 11 6 Cancer Respiratory disease Injuries/accidents Diseases of the digestive tract Nutritional and metabolic diseases Psychiatric disease Diseases of the nervous system.772 1. 3) Includes only general practitioners. chiropractic.617 2.620 1.410 100 26.896 1.0 27.0 8.169 978 1.320 8.545 10.886 4.8 1.088 12.8 36.5 5.8 4.361 12.305 5.907 909 1.617 2.5 33. 8) Includes production costs of 2.2 11.1 60. Source: Nastra Recommendations nr.5 38.5 7.2 1.3 billion Danish DKK related to suicide.615 9.2 21.080 6.371 6.998 12.8 1.7 85.504 11.4 39.144 3.882 3.8 1.0 39.5 72. discounted by a factor of 4%.8 5.895 493 7.925 15.697 550 2.902 5.7 4. the disease specific distribution of costs of both direct and indirect costs 6) Of non-permanent character.7 12.
The numbers cover the entire musculoskeletal disease area and as previously stated low-back disease contribute approximately 50% of the costs of this disease group. Note that the direct costs of this group are less than several of the other groups. the large indirect costs result in the great total costs related to this disease group. In our group we concluded that it was impossible to acquire more precise data without initiating several costly analyses.may be present simultaneously. The yearly costs to society are therefore roughly 10 billion DKK. Only psychiatric diseases are more costly to society than muscoloskeletal disease. Indirect costs can be evaluated by using data from the whole disease group “musculoskeletal diseases. However.” Table 5 shows both the direct and indirect costs of 13 chosen disease groups. We conclude that considerable savings will mainly come from reducing the indirect costs. 22 .
Examples include conscious inactivity. self-treatment. a clear relationship between pain intensity and treatment although approximately 68% of individuals suffering from severe pain do not seek treatment even though 88% of these individuals do not believe that their symptoms will subside. physiotherapists or chiropractors (Table 8. however. A group (12%) will seek help from a chiropractor either separately or at the same time that they contact their general practitioner. and seeking help from health professionals as well as from friends and family. page 24). page 24). Many individuals (approximately 30%) suffering from musculoskeletal symptoms do not alter their activities of daily living nor do they seek help in the form of treatment (Table 6. A large group attempt to tackle their low-back pain problem by altering work patterns. The percentage of individuals that seek care due to low-back pain related functional disabilities are greater than those suffering from other diseases of the 23 . page 25). Thirty-seven per cent of individuals suffering from low-back pain will seek treatment within a year (DIKE 1995). The vast majority of treatment is provided in the primary health care sector by general practitioners. Only a small percentage will be examined and treated by a specialist in rheumatology or at a hospital. or by participating in preventative ﬁtness training programs (Figure 2. it is unlikely that this group differs from individuals suffering from other forms of musculoskeltal pain. There is no data in the DIKE report which deals speciﬁcally with low-back pain. There is therefore. (Table 7 page 24). Individuals suffering from severe pain or disability will naturally seek help from health professionals at greater rates than others.2 Illness Behaviour Illness behaviour includes all forms of reactions resulting from signs and symptoms of a disease. Twenty-three per cent of individuals suffering from low-back pain that seek professional help will initially contact their general practitioner. Slightly less than ﬁfty per cent will be referred to a physiotherapist (9% of all patients seeking help). changing the ergonomics of their workstations.
Source DIKE 1991 24 .5 4. of which 35% have had trouble with back pain during the past year and 37% of whom have sought treatment.4 11.758.000 83.000 545.000 174.000 404.TABLE 6 Illness behaviour among males and females in different age groups suffering from musculoskeletal symptoms during the past 14 days given in percentages (%) Males 16-24 Has done nothing Self-treatment only Self-treatment and sought professional care Only sought treatment In total Source DIKE 1991 Females 25-44 34 50 12 3 100 45-66 33 51 15 1 100 67+ 42 47 7 4 100 Total 36 49 12 3 100 16-24 29 60 8 3 100 25-44 21 62 14 2 100 45-66 22 62 13 3 100 67+ 35 47 13 6 100 Total 25 58 13 3 100 M+F 30 55 12 3 42 44 9 4 100 TABLE 7 Percentage of differing illness behaviour among people with different types of musculoskeletal symptoms given in percentages (%).5 Number of treatments* 417.000 1. Percentage with contact (%) general practitioner Physiatrist or rheumatologist in private practice Doctor at a hospital department Physiotherapist at a hospital Physiotherapist in private practice Chiropractor Total number of treatments 23 4 4 4 9 12 Average number of contacts 3. *The number of treatments is derived from the fact that there are 4 million Danes over the age of 16.000 The same person can have received treatment from several health professionals.0 8.5 6.000 135. With severe pain With reduced activity levels Are not capable of doing what what they would like to Have symptoms from several areas of the body Tired due to symptoms Have had symptoms for a longer period of time Do not expect that their symptoms will resolve Has done nothing Self-treatment only Sought treatment (and eventually did something themselves) In total Source DIKE 1991 14 54 20 49 24 52 25 57 21 55 30 56 32 56 33 100 31 100 24 100 18 100 24 100 14 100 12 100 TABLE 8 The number of consultations with health professionals during the past year and the number of treatments from all individuals suffering from low-back pain.7 6.
This can be interpreted to mean that low-back pain related symptomatology is perceived as requiring more treatment than other diseases of the musculoskeletal system.FIGURE 2 The percentage who attempt different things in order to reduce symptoms due to musculoskeletal trouble 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 0% Source DIKE 1995 10% 20% 30% 40% 50% musculoskeletal system (10-20%). The increase in the number of back complaints must 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 . N N N N N 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.
a clear separation of these factors is not always possible. Similarly. to represent. For example. unknown factors may play a role in the development of low-back pain as may factors that have not been recorded. while external factors most often relate to work or social factors. However. risk factors regarding the development of acute and chronic low-back pain oftentimes overlap. there are factors. However. Our knowledge regarding possible risk factors has been derived from large population studies where a statistical correlation between risk factors and low-back pain in the studied population has been frequently demonstrated. Utilising the term factors can therefore result in misunderstandings while the term indicators (to be a sign of. Furthermore. risk factors are divided into individual and external groups. Generally the term factors is more commonly used in the literature and we will follow suite in this report. but should not be confused with a cause and effect relationship which requires secure knowledge regarding a direct relationship between an injury resulting in low-back pain. for a number of factors there is solid documentation of a relationship between exposure and the general development of lowback pain. The degree and duration of exposure will inﬂuence both the development and the course of low-back pain. The scientiﬁc literature in this area is rather unclear both regarding the clear deﬁnition of the involved terms as well as the statistics employed. where there is no clear separation between the different risk factors. Traditionally. A series of different factors are important as regards the frequency as well as the duration of low-back pain for the individual per26 . The relationships are very complex due to the fact that many factors have to be evaluated at the same time. Individual factors are related to the person in question. which contribute to the development of chronicity. many risk factors have not been examined as far as their relationship to one another is concerned. This can be seen in Figure 3.3 Risk factors (indicators) Risk factors relates to factors that have a probable inﬂuence regarding the development of as well as the course of low-back pain. or to reﬂect) more accurately describes our concerns. Results from research may present conﬂicting conclusions. Additionally.
and ongoing litigation/pension procedures. decision makers as well as the population at large have been led to believe that back-pain is most often due to many years of heavy lifting or inappropriate seating postures. Oftentimes. During the course of the last twenty years. low levels of job satisfaction. all known risk factors be addressed (both individual and external). stress or depression. it will be of great importance to study risk factors responsible for the development of chronic low-back pain because this oftentimes results in patients being sick-listed for several years. A great number of lowback complaints are a result of other social as well as individual factors. This has logically resulted in preventive measures being undertaken at the workplace aimed at reducing the pace of work as well as the number of heavy lifts. We cannot for example conclude that “heavy lifting” contributes more frequently to the development of low-back pain than either “psychological stress or low social status”. At the present time it is not possible to propose a list. smoking. This is in all likelihood due to the fact that only some of the cases of back-pain are mainly work-related. but they should not be regarded as obligatory.son. N N Individual risk factors are at least as important regarding the development of low-back pain as are external factors Future preventive measures must address both individual and external factors 27 . Risk factors of importance as far as this issue is concerned include: long-term sick-listing. and ending with permanent disability pensions. ranking the most important factors. In Figure 3 a series of risk factors are presented under the heading “proven”. In the future. During this period. receiving endless amounts of treatment. These factors are regarded by most experts as being most frequently involved in the development of low-back pain. It is essential that in future preventive activities. exaggerated illness behaviour. several risk factors (both known and unknown) acting simultaneously will affect the course of low-back pain and it can be impossible to determine which of the factors is the most important. Among the HTA participants there is agreement that “individual factors” are at least as important regarding the development of low-back pain as are the external factors. the number of people suffering from low-back pain has unfortunately increased markedly.
marital or economic difficulties. 2) Proven as regards chronic back-pain but should be considered a possible risk factor as regards acute back pain. Great risk for females over age 60. 3) Alcohol. 28 .FIGURE 3 Possible and proven risk factors regarding the development of low-back pain Possible will be presented in normal font. Individual risk factors Age (1) Poor general health Poor physical health Genetic disposition Personal problems (3) Psychological stress (2) Reduced endurance of the spinal muscles Alcohol abuse Smoking Low social class Work-related/compensation-/ pension ongoing Previous back pain Radiating pain to the leg External risk factors Sedentary work Many aggrevating twisting Depression Long term sick-listing Clinical impression of disc herniation Exaggerated illness behaviour Highly repetitive work Poor job satisfaction Driving > 2 hours Obesity Many heavy lifts Risk factors for the development of chronic low-back pain 1) Greatest risk for males aged 40-50.while proven will be given in bold type.
which are based upon patient symptom description. None of these attempts at classifying patients has been comprehensive enough to cover the wide spectrum of low-back pain. These divisions have been shown to be of value regarding the health professionals’ need of further examinations and treatment strategy design. Degenerative low-back conditions.4 Diagnostics D IAGNOSES During the years many different diagnostic classiﬁcation systems of low-back pain have been devised in order to arrive at a likely diagnosis. spondyloarthrosis. Non-speciﬁc low-back pain is divided into the following classiﬁcations. which can commence at different periods of an individual’s life. causes or symptoms. disc degeneration/herniation. Due to a lack of solid biological causes the terms “non-speciﬁc back pain” or “simple back pain” have become widely used. This is possible in approximately 30% of low-back pain patients. This of course depends upon a clear correlation between anatomical ﬁndings and patient symptoms. Severe degeneration of the spine can result in either constant or periodic pain. Emphasis has either been placed upon the anatomic localisation. This term covers a variety of conditions including spondylosis. Our present knowledge regarding the biologi29 . Spinal degeneration is a natural phenomenon. and is generally considered to imply degeneration taking place somewhere in the spine. N N N N 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. It has become accepted in professional circles that it is impossible to make a speciﬁc diagnosis in approximately 70-80% of cases regardless of how thorough the examination procedures have been.
cal mechanisms of spinal degeneration and their relation to spinal symptoms is very sparse. These nerves are a part of the sciatic nerve. Even severe degenerative ﬁndings do not necessarily result in symptoms. Spinal stenosis refers to a condition with reduced space in the spinal canal due to degenerative changes. A OVERVIEW OF DIAGNOSES IN WHICH THERE IS A CORRELATION BETWEEN OBSER VED FINDINGS AND SYMPTOMS Degenerative Conditions: Spondylosis/disc degeneration at several levels Spondyloarthrosis Disc herniation Spinal stenosis Other: Scheuermann’s Disease Discitis Infectious spondylitis Osteoporosis Spinal tumors Spondylosis/disc degeneration (osteoarthritis of the bones or discs) can be identiﬁed with the following x-ray ﬁndings: Reduced discal height. In conditions. the long-term prognosis is most often favourable. It has been shown experimentally. Spondyloarthosis usually develops as a result of reduced disc height. Due to the anatomy of the region there is a poor correlation between joint degeneration and pain localisation. Disc herniations can also be found in individuals that have no symptoms at all. Disc herniation is commonly associated with low-back pain in the general population. however radiating pain to the leg and weakness of the foot are frequently observed. that facet joint irritation can result in gluteal pain. Symptoms result from the nucleus of the disc pressing on the spinal nerves and/or resulting in a chemical irritation of the nerves due to tears in the discal ﬁbbers. In spite of the oftentimes dramatic course of events in the acute phase of a disc herniation. sclerosis of vertebral bodies or calciﬁcation of the discs. Only one out of four patients require surgery. Symptoms can vary according to the level of the disc herniation. for example. X-ray ﬁndings usually correlate poorly with symptoms. Spondyloarthrosis (degeneration of the true joints of the spine) refer to degenerative changes of the facet joints between the vertebra. which result in 30 .
This disease is most commonly seen in the thoracic spine (chest) although it can also be found in the low-back. This process takes place during puberty and is more commonly found in males. Symptoms usually develop after a period of time. or in drug abusers. If however. muscles and connective tissues. This results in an alteration of the shape of the bodies of the vertebra from the classic block-like form to a wedge form. a spondylolisthesis results in a vertebra slipping forwardly on the vertebra below symptoms may develop. scoliosis may also be a result of changes in the vertebra. This is a common ﬁnding in 5% of the adult Danish population and can be found in 35% of the Eskimo population. Initial symptoms include fever and back pain.symptoms due to pressure on the nerves. Scoliosis is a condition with unusual curves of the spine in the side plane which can be a result of unequal leg lengths (non-structural) in as much as 20-30% of the population. among the elderly. Sacroiliitis/Ankylosing spondylorarthritis is an inﬂammatory pro31 . Discitis is an inﬂammatory condition (sometimes bacterial) in the discs of the spine. However. This condition can also be found as a result of degeneration of the disc or facet joints. Scheuermann’s disease occurs in the growth zones of the vertebra. This disease is usually found in individuals with weakened immune systems. Infectious spondylitis is a bacterial inﬂammation localised to one or more vertebrae. It most frequently results after surgery (1-2%). This condition does not necessarily result in pain. The bacteria usually spreads through the blood. in individuals with systemic disease (diabetes). In younger people scoliosis is due to a developmental defect while in older individuals it is oftentimes seen in association with degenerative changes in the spine. It is characterised by extreme tenderness to pressure of the adjoining vertebrae. Symptoms resulting from a thoracic Scheuermann are rare whereas symptoms from the low-back are 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. the most usual symptoms are pain and decreased strength in the legs.
or bladder. which is oftentimes worst at night.cess in the joints of the pelvis and the sacrum as well as in the joints of the spine. Symptoms include pain. The course can be either slow or quick depending on the localisation of the tumor. Osteoporosis refers to a lack of calcium in the bones resulting in changes in structure which may result in fractures after seemingly minor trauma. This process can be found in conjunction with other arthrotides or independently. Most patients are from 50-60 years of age but tumors can be found in all age groups. Spinal tumors include both benign and cancerous tumors. weakness and sensibility changes in the legs. 32 . breasts. This results in a negative balance in the process of during which bone tissue is renewed and torn down. Primary spinal tumors are quite rare and most are a result of metastasising cancer from either the lungs. Osteoporosis is most frequently seen in elderly females due to decreased estrogen production after menopause.
The interview includes a thorough round of questions regarding how and when the pain developed as well as the course of the symptoms. The primary purpose of the clinical examination is to attempt to make a speciﬁc diagnosis as well as to make sure that there is no serious illness present.5 Diagnostic procedures For most patients suffering from low-back pain a thorough interview and clinical examination will sufﬁce. determine if additional examinations are necessary and initiate treatment. A particular problem is the differing attitudes regarding the validity and interpretation of certain clinical tests both intra. which may require further examination. Information regarding previous episodes of low-back pain is also relevant to discuss. which are described below. The clinical examination should include a relevant number of the diagnostic tests. 33 . A thorough examination is also necessary in order to determine the most appropriate treatment strategy for the patient and to avoid unnecessary repetitive examinative procedures. This oftentimes results in patients receiving contradictory information. the initial examination is the singularly most important activity as regards the management of the low-back patient. In the opinion of the HTA group. The interview is followed by the clinical examination.and interprofessionally. A comprehensive review of potential risk factors regarding the development of chronic low-back pain is also of extreme importance. These procedures will reduce the likelihood of there being an underlying pathology. which is causing the low-back pain in either acute or chronic low-back pain. It may also be possible to weigh the risk of chronic symptom development and to initiate preventive measures. If properly carried out one can evaluate the magnitude of the patients problem.
T HE CLINICAL EXAMINATION
1. 2. 3. 4. 5. 6. 7. 8. Postural anomalies (curved spines) Spinal motion 3. Gait analysis Pain tests (tenderness of the spine) Lasegue’s test (straight leg raising) Neurological tests (sensibility, reﬂexes, strength) Rectal examination Para-clinical tests (x-ray, blood)
I MAGING ( X - RAY, CT AND MRI - SCANS ) AND SPINE DIAGNOSIS
Traditionally, a x-ray of the spine is one of the ﬁrst examinations undertaken in low-back pain patients. However, this examination for the most part does not provide any meaningful information for the majority of patients, as x-ray ﬁndings generally correlate poorly to symptomathology. Additionally, x-ray ﬁndings rarely provide useful information regarding the course of the problem such as the risk of developing chronic symptoms.
L Only in circumstances where the health professional suspects the presence of infection or other inflammatory conditions, fractures or cancer will x-rays provide information of importance regarding further examinative procedures and treatment.
It is the opinion of the HTA group that x-rays should only be generally entertained if the low-back pain has been present for at least four weeks. Ordering x-rays earlier in the course of events is not ethically or economically acceptable. Only in circumstances where the health professional is led to believe that other diseases may be present can the above conclusions be circumvented. One should attempt to secure previously taken x-rays (1-2 years old) at the initial consultation and to make sure that patients have their x-rays with them if referred to other health professionals in order to prevent unnecessary x-ray exposures and delays. The reason that x-ray examinations are oftentimes repeated is that they cannot be retrieved quickly enough or due to poor quality. The HTA group strongly recommends that guidelines for “proper x-ray procedures” for low-back patients be prepared. This can be done through co-operation between radiologists, surgeons, chiropractors, rheumatologists and so forth. It is also necessary to evaluate the best method
of storing x-rays so that health professionals can retrieve them as quickly as possible so that treatment strategies are not delayed. More advanced imaging such as CT and MRI -scans (with or without contrast ﬂuids) are rarely indicated in acute low-back pain for the same reasons as mentioned above. Scanning procedures should only be entertained if patients are experiencing functionally disabling symptoms such as severe back or leg pain for more than month and/or if surgical is likely. The x-ray procedure involving the injection of contrast ﬂuids in the spinal canal (myelography) is still commonly used in hospitals even though the information provided is similar to that of other procedures. Myelography is not used as frequently as in previous times due to the risk of pain development, severe headache (days to weeks) and the slight risk of infection. The HTA groups suggest, in accordance with international trends, that less invasive procedures such as CT or MRI scans be used as the standard procedure in the investigation of disc herniations as opposed to myelography. In cases where there 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 to place, with x-rays ranging from 375-1000 DKK myelography 2500 DKK, Ct-scans 4000 DKK and MRI-scans 7000 DKK. These ﬁgures do not include costs associated with treatment and eventual side effects. Considerable amounts can be saved by avoiding unnecessary examinations or repeated examinations and if these procedures are (as far as is possible) initiated only if surgery is being entertained.
B LOOD TESTS
In the vast majority of cases of low-back pain it is not necessary perform a blood examination. Indications for blood tests include suspicion of infection, other inﬂammatory processes or malignancies. The type of blood tests required will depend upon information gathered from the interview and clinical examination. The following blood tests will be sufﬁcient for initial diagnostic considerations: Hemoglobin (blood percent), white blood cell count, serum creatinine (kidney function), serum calcium (bones), basic phosphates (bones), and blood sedentary rates (general sickness indicator). Additionally, it may be relevant to examine the urine for blood and white blood cell counts if there is any suspicion of urinary disease. If the above mentioned tests are all negative it is highly unlikely that low-back symp35
toms are a result of any inﬂammatory process or other metastatic disease. The HTA-group recommend that reference programs including guidelines as to what blood tests should be done and in which circumstances. Superﬂuous examinations are not only expensive but they also are associated with promoting illness behaviour and inducing unnecessary fear on the part of patients. Prices for the individual blood tests cannot be given because the cost of equipment is far greater than costs associated with carrying out individual tests. Therefore, the cost of singular tests is dependent upon the total number of tests that are done. Total costs will only be reduced minimally if the number of examinations are fewer and conversely will only increase markedly of the number of tests ordered increases dramatically resulting in the purchase of additionally equipment and the hiring of additional personnel.
N N N N
In 70-80% of cases it is only possible to arrive at the diagnosis “nonspeciﬁc” low-back pain, even after a thorough examination A diagnosis based on a secure pathoanatomical foundation can only be made 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 professional 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 if pain continues for more than 4 weeks
and the widespread practice of undocumented treatments. The selected health professional is responsible for the manner in which the patient is taken care of initially. page 24).6 How Do We Address the Low-Back Problem From An Organisational Standpoint? A considerable increase in the utilisation of both authorised health care professionals as well as alternative practitioners in the past years is in all likelihood due to a variety of factors including: Our present lack of diagnostic capabilities. the health care system is composed of primary and secondary sectors. Two-thirds of individuals suffering from low-back pain consult their general practitioners initially and one-third contact a chiropractor (Table 8. Patients can be examined and treated by general practitioners and chiropractors with support from the National Health Care insurance. and the promotion of illness behaviour. Figure 4 present the structure of the system as well as the placement of the different health care professions. Due to a lack of co-ordination in the authorised health care system many “services” are repeated. In the Figure. T HE PRESENT HEALTH CARE SYSTEM At present. the unwillingness of individuals to “accept” pain. 37 . formal referral routes are presented with arrows and informal referral routes are presented with dotted lines. only when referred by a general practitioner Treatment at hospitals is also dependent upon a referral from a general practitioner. unnecessary costs. a specialist or a physician on call. Patients receive ﬁnancial support from the national health care insurance when being examined and treated by physiotherapists and specialists. For example. a patient may be consulting a chiropractor and a physiotherapist at the same time without any communication between these professionals taking place. This lack of co-ordination results in inappropriate patient strategies. X-rays may be taken at the chiropractic clinic and ordered from the regional hospital at the same time.
patients should not be hospitalised due to low-back pain. We recommend that as a rule patients not seek care at hospital emergency wards due to acute low-back pain because most acute wards are not geared to handle this type of problem. This is the only way to minimise the duplication of services. hospitalisation is of course recommended. treatment results and so forth. examination and treatment strategies should be the same. Inactivity is promoted and costs are high. In the opinion of the HTA-group. The organisational planning of low-back pain treatment and assessment should be carried out in accordance with the scope of practice of authorised health care professionals.S UGGESTIONS FOR THE FUTURE ORGANISATION OF LOW . In circumstances of serious illness and extremely severe pain. Referrals to specialists should not be undertaken prior to comprehensive assessment and treatment in the primary health care sector. the promotion of illness behaviour. and unnecessary costs due to factors such as distance. N N N N N N N N N Irrespective of whom the patient consults. Individual patient information is always a central aspect of assessment and treatment. During treatment close co-operation between relevant health care professionals for example exchanging journals (with patient permission). It is important to avoid unnecessary waiting times. Hospitalisation increases the likelihood of promoting illness behaviour due to patients’ lack of control over the situation. Treatment should be carried out in the primary health care sector and preferably in the region where the patient lives. both the formal and informal referral channels presented in Figure 4 should be upheld. 38 . Referral to a specialist or a hospital department should take place quickly if 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 care sector. We have concluded that a more thorough evaluation of the future roles of the differing health professional is not a part of the HTA-commision. x-rays.BACK PAIN ASSESSMENT AND TREATMENT The HTA-group is in agreement regarding the following recommendations regarding the organisation of the manner in which low-back pain should be handled. Generally.
two-thirds of patients contact their general practitioner initially and one-third contacts a chiropractor. As previously mentioned. These two health professions should formalise their communication channels so that relevant patient information can be readily retrieved by each group. hospitalisations and so forth and therefore plays a central role in the public health care system. Due to the fact that chiropractors and general practitioners represent the most commonly utilised health professions as regards ports of entry into the public health care system for the treatment of lowback pain. The general practitioner is also the referral source to physiotherapists. The general practitioner already has information regarding previous disease. Thorough and individualised patient information regarding the diagnosis. underscores the importance of increasing communication regarding mutual patients with low-back pain. and treatment strategy should always be a central aspect of all patient consultations for low-back pain. treatment and prevention of biomechanical lesions in patients with back-pain. the general practitioner and the chiropractor. The scope of practice of chiropractors includes the diagnosis. specialists and hospital departments as well as being the individual that does any necessary follow-up work.FIGURE 4 Present health care sector Primary health care system General practitioner Physiotherapist Secondary health care sector Hospital department/outpatient Emergency ward Specialist Chiropractor Relaxation therapist Psychologist There are two ports of entry to the public health care system regarding the treatment of low-back pain. The scope of practice of the general practitioner when dealing with low-back pain is to make the initial diagnosis and initiate treatment and preventive measures. prognosis. 39 .
Roughly 50% of patients will be free of symptoms within 3 weeks and 90% within 3 months. Unnecessary and perhaps risky treatments can by themselves contribute to maintaining or even worsening symptoms and promoting illness behaviour. People need to be informed about the positive prognosis most commonly associated with low-back pain whether treated or not. An important aspect of the future national strategy regarding the improvement of low-back pain treatment will be public information campaigns. N Low-back pain accompanied by decreased strength in one or both legs 40 . Many people with low-back pain do not need to consult a health professional. it is necessary that people are informed about the positive prognosis of most episodes of low-back pain. In the future it will be important to inform the population about when it is appropriate to consult the health care system and when it is not necessary.BACK PAIN As previously mentioned acute low-back pain is deﬁned as pain of less than 3 months duration. Most episodes of low-back pain resolve by themselves and only rarely do chronically disabling symptoms develop. In order to prevent unnecessary contact to the health care sector. The HTA-group recommends that public information include the following: IMPORTANT PUBLIC INFORMATION Many people develop low-back pain. Ten per cent of patients will experience chronic or recurring symptoms. 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: N The pain is severe N If the pain prevents you from carrying out your daily activities for several days N If the pain does not resolve within a few days If your are experiencing the following symptoms contact your doctor immediately! N Low-back pain accompanied with an inability to control bladder function and a lack of sensation in the groin area. The information must not dramatise the issue but must also include clear guidelines as to when one should consult a health professional.ACUTE LOW . Important facts to know! Low-back pain is only rarely a result of a serious illness.
blood ( haemoglobin. serum creatinine) and urine tests for the presence of blood. phosphates.In the opinion of the HTA-group. If unchanged or worsened: Evaluate the need for further examination or refferal 1) If suspicion arises regarding fracture. or inﬂammatory disease (especially arthritic disease): X-ray. or refer If satisfactory. malignancy. If there is suspicion of lost bladder function or progressive weakness in the lower limbs acute referral to hospital 41 . sedimentation rate. order additional tests. infection. patients that consult general practitioners and chiropractors should be examined. white blood cell count. observed and treated according to the guidelines presented below The suggested course of managing acute low-back pain divided into 2 week modules First consultation: Interview and clinical examination and determination if additional diagnostic measures and treatment are necessary Conclude case Evaluation at hospital (1) 2 weeks of treatment According to needs: Observation or treatment Status after 2 weeks Determine wheather to continue treatment. conclude case If unchanged or worsened. re-evaluate Additional 2 weeks of treatment Status after 4 weeks If satisfactory omprovement: Conclude or plan continued care or rehabilitation.
if the patient has been referred. N N N N 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. In other cases the course should be addressed in a multi-disciplinary fashion.It is important that the process including examination and treatment includes goal setting as regards treatment results and that both the health professional and the patient are conscious of these goals. Treatment results should be evaluated with documented assessment instruments. If the patient wishes. In Denmark the Copenhagen Back Research Association has developed an widely used evaluation journal and the Danish DiscBase employs a similar instrument. this information should be sent to other health professionals. The latter may require several months of treatment/observation.BACK PAIN Chronic low-back pain is deﬁned as pain lasting for more than 3 months. Generally. Patients suffering from chronic pain (depending upon the severity of the problem) are a socially threatened group. In certain circumstances advice regarding the work place and activation regarding increased physical activity will sufﬁce.and if more than one health professional is involved. The most appropriate examination and treatment program for chronic patients cannot be structured in the same rigid manner as the case is for acute low-back pain. Chronic pain will oftentimes lead to sick-leave and many series of treatments. Examination and treatment results should be reported to the patient’s general practitioner (conditional upon patient’s agreement) in a readily understandable fashion. An individual strategy must be planned for each patient.a high level of communication must be established Continued evaluation of the course and individual information is important 42 . C HRONIC LOW . A quick and effective examination and treatment strategy must be implemented in order to avoid worsening. Most counties in Denmark do not have facilities. which can manage these cases. Suggestions regarding the future organisation of low-back pain assessment and treatment should be acted upon. a good rule to follow is that the magnitude of the examination and treatment procedures should reﬂect the magnitude of the problem. Xrays and blood work will frequently be necessary.
Waiting times for surgery (if indications are clear) should not exceed 2-3 weeks. Waiting times of more than a week to consult a health professional or 2-3 weeks to consult a specialist is unwarranted.OPERATION The HTA-group is of the opinion that co-operation between the different health professionals that deal with low-back pain is unsatisfactory. chiropractors and physiotherapists should be expanded in 43 . This is already in use with obstetrics patients. Long waiting times also affect the prognosis of low-back pain negatively because it becomes increasingly difﬁcult to successfully treat individuals whose status is affected by these psychosocial factors. Possible solutions to this problem have been discussed in our group. Common post-graduate courses for physicians. The need of a long-term and costly rehabilitative period also increases as does the likelihood of developing associated problems such as stress. which results in all relevant professionals of being aware of previously undertaken diagnostic measures and treatment. The likelihood of returning to work (with an intact work capability) decreases considerably if disabilities last for more than 13 months. a continuous theme in the answers given was the poor communication between different professionals. A good opportunity to reduce the number of patients suffering from chronic disabling low-back pain including the indirect costs due to loss of ability to work depends upon reducing waiting times for relevant examinations and treatment. According to our interpretation of the data presented in this report.7 Summary and suggested areas of focus WAITING TIMES Long waiting times for examination and treatment increase the risk of developing chronic symptoms.DISCIPLINARY CO . a system. anxiety. and depression. I NCREASED INTER . This has been demonstrated in DIKE’s report from 1995 entitled “The Health Care System’s Handling of Back Pain”. One possibility is the establishment of “wandering patient ﬁles” which go with the patient. This is due not only to differing ways of addressing the problem but also to a lack of formalised communication between health professionals.
I NDIVIDUAL 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 with a certain degree of pain and disability. In situations such as these. It is important that patients become activated as early as possible in their treatment programs. Practice co-ordination must be evaluated and expanded so that it not only involves private practice and the hospital sector but also between health professionals and the social and communal sectors. such as social and occupational workers should be upgraded.order to promote a more uniform attitude towards low-back pain patients and furthermore that commonly utilised terms/classiﬁcations have more common ground than at present. These courses should also involve other relevant health care groups such as psychologists and relaxation therapists. Even if the most appropriate diagnostic and treatment methods are used. it is not always possible to cure all patient symptoms. Patients must be made aware of their own responsibilities and must also be activated to participate in an active rehabilitation program. The quality of post-graduate education in both the primary and secondary health care sectors could be enhanced by establishing more professorships and associate professorships. The information phase requires 1-2 hours on the part of the health professional depending upon the magnitude of the problem. We should strive after a situation where decisions made by these individuals are in as close agreement as possible with the latest scientiﬁc knowledge in the area. This is most readily achieved with a thorough information phase. Several health professionals with different backgrounds can be involved in the information phase. in spite of symptoms. This is the best way to maintain their social position. work and leisure activities must be adjusted in order to maintain as high a level of “quality of life” as possible. 44 . It may be necessary to repeat information regarding all aspects of the strategy several times in order for patients to develop a good insight into the situation. We suggest that a committee with representatives from all relevant health care professionals be established in order to address the issue of improving inter-professional co-operation and post-graduate education. Special courses for other participants on the low-back issue. Information provided should be individualised and based upon the individual patient’s situation and needs.
RAY EXAMINATION OF THE SPINE X-rays are very often taken too early in the course of events.Existing governmental supported programs such as “adult education” and “spare-time education” should also be utilised for this purpose. P UBLIC INFORMATION Information to the general public is an area. The only way to avoid unnecessary exposures and to increase the quality of x-rays is to develop guidelines for the taking of x-rays and to develop formalised lines of communication between heath professionals. which needs to receive more attention in the future. They must be made aware that an episode of low-back pain is not dangerous and that successful treatment results depend upon their participation. X-rays are also repeated within too short a time frame due to poor communication between the general practitioner. Individualised patient information is so important an area that we believe that it should be perceived as an independent “service” and paid for accordingly. Additionally. X. This type of information must be made available to the population at large. they should be repeated several times in order to enhance their effect. The population needs to be made aware of our strengths as well as our limitations as regards examination and treatment. 45 . the chiropractor and the hospital. which should be focused upon. Guidelines should be developed by the relevant professional societies as soon as possible. It is the opinion of the HTA-group that a strengthened individualised information effort both in the primary and secondary health care sectors is an important area. Public information campaigns should be planned and carried out with the help of health professionals as well as experts in communication. Formalised communication channels need to be established in order to secure that x-rays and their descriptions are always at the relevant place at the correct time. as does the likelihood of curing the patient. Far too often one witnesses long-term treatment that has not resulted in a complete cure. This duplication of service is unacceptable also as regards unnecessary radiation. General agreement needs to be attained regarding the practical aspects of taking x-rays as well. Patients become disappointed because of unrealistic hopes and inadequate information. If chronic pain develops our diagnostic possibilities become limited.
Other examples of central registration of treatment results include the database developed by the Copenhagen Back Research Association (COBRA). Treatment of severely pained patients as well as chronically disabled patients can be carried out at these centres in order to reduce the number of patients that become hospitalised. It has never been proven that patients beneﬁt from hospitalisation. It is extremely important that projects such as these continue both in the primary and secondary health sectors and that adequate funding is made available. which is a nation-wide registration of the clinical results obtained from disc herniation operations. These databases should utilise validated outcome measurements that are comparable. which may lead to increased passiveness and illness behaviour. The great majority of acute and chronic patients can be examined without the patient being hospitalised. Hospitalisation can result in differing and confusing information being given to the patient due to his/her coming in contact with so many different people. The registration of patient data in clinical databases should become standard procedure for every health professional. page ??).H OSPITALISATION / AMUBULATORY TREATMENT / MULTI . This is the only way in which we can develop a picture of the overall treatment effort/results. Preconditions for successful outpatient examinations are. that centres have multi-disciplinary teams. Hospitalisation is only indicated under certain conditions. An example of this effort is the Danish Disc Base. As previously stated. Multi-disciplinary teams with the resources to carry out high quality outpatient examinations and treatment should be established in several areas throughout the country. This effort will be completed within 1-2 years and the information gathered from it will contribute to improving the future treatment of disc herniations. Additionally. patients are prone to place the entire responsibility for their conditions on the hospital staff. that only a few people are involved with a patient and that time is taken to give the patient comprehensive and individualised information.DISCIPLINARY TEAMS Many patients are hospitalised due to low-back pain (Table 4. The results obtained from these databases will form the bases of reference pro46 . Q UALITY CONTROL : DATABASES & REFERENCE PROGRAMS The development of a systematic registration of treatment results through clinical databases has only recently begun. a precise diagnosis cannot always be made.
I NCREASED KNOWLEDGE OF THE COURSE OF TREATMENT Our knowledge regarding the documentation of how speciﬁc and clear diagnoses are arrived upon as well as which treatments are most effective for speciﬁc conditions and when these treatments should be administered is lacking. clinical databases. T EACHING / RESEARCH Many issues relating to the diagnosis and treatment of low-back pain have not been resolved. How many x-rays are taken? How many injections are given? Do these treatments help? The lack knowledge in this area has limited our HTA-group from arriving at clear recommendations involving economic issues. Interdisciplinary work groups should also be established. This information need not take the form of randomised clinical trials. Increased inter-disciplinary course activity should also be promoted actively. should be carried out by all health professional associations. Specialist education should be planned so that “ordinary” low-back patients are seen regularly as well. in addition to establishing data bases and increasing scientiﬁc 47 . We also lack information about how patients are treated presently in the public health sector as well as whether the results obtained are superior to the natural course of events. Formalised post-graduate education and courses should be emphasised in order to insure that patients are treated in accordance with the newest knowledge in the area. prospective observational studies. We should insure that the development of these clinical databases is undertaken with the participation of all relevant health professional associations and that funds are provided for this work. which emphasise the latest knowledge regarding the diagnosis and treatment of low-back pain patients. We must insure that specialists in rheumatology continue to participate in the professional arena of low-back pain. The education of these specialists should not be limited to “rare” cases as has been the case in the last decade. These reference programs will insure professional development based upon factual evidence. reference programs and economic planning. In the future it will be necessary to have concrete information about all of the abovementioned issues in clinical databases.grams. Courses. The HTA-groups suggests that. There is great need to carry out a large number of controlled trials in order to enhance our knowledge. The code words in these activities include: systematic registration.
Future professional fee schedules can be determined according to scientiﬁc merit and can therefore serve as a regulatory method to enhance the quality of care provided N N N N N N 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 treatment procedures Strengthen research and education 48 . Increased research will document which treatment activities are useful and which ones are not. This is the most effective way to secure the needed emphasis of this important aspect of treatment. This is necessary in order to effectuate a practical strategy.ORDINATION OF EFFORTS / PROFESSIONAL FEE SCHEDULES A will to confront these issues needs to be demonstrated at the highest levels.work. T HE OVERALL CO . Future public health fee schedules should reward the “information” phase of any treatment as an independent service. The re-distribution of resources should instead channel resources to the areas outlined in this manuscript. Is there a difference in the treatment given within the same health profession? Are there geographical differences? Does treatment help? Is the likelihood of developing chronic symptoms reduced? Why does treatment seemingly help for some people but not for others? What are the costs involved in each treatment? The answers to these questions and others will make it possible to determine the most appropriate treatment courses and this information will form the framework for future reference programs. The re-distribution of resources should not end up resulting in simple money saving acts such as reducing the number of available hospital beds for low-back patients. This will entail considerable changes in the different health disciplines as well as increased coordination between the different groups. the mapping out of observational data which describe what happens to the average person when patients experience a bout of low-back pain be undertaken. In the opinion of the HTA-group present fee schedules reward “treatment”. The project will be made complex by the fact that so many different health professions are involved.
Low-Back Pain Volume 2 49 .
Patients receive reimbursement from the health care system when receiving chiropractic care whether or not a physician has referred them.1 The various Danish health professions that treat patients with “low-back pain” There are in Denmark several different health providers. or a hospital department. both authorised and unauthorised. the general practitioner can recommend the patient to seek a chiropractor. Preventive treatment and social service can also be initiated. Furthermore. a specialist. treatment and prevention of biomechanical functional lesions for patients suffering from low-back pain. The general practitioner (specialist in general medicine) in the primary health sector In the Danish health care system the general practitioner has always played a central role in the treatment of an individual’s illness. The chiropractor in the primary health care sector The scope of practice of a chiropractor includes the diagnosis. The general practitioner can also refer patients for additional examinations or treatment to a physiotherapist. Chiropractors received their public authorisation in 1992 and can examine and treat low-back patients independently. Information regarding examinations and treatment results should be forwarded to the general practitioner if the patient so wishes. In addition to manual treatment the most im51 . which traditionally examine and treat patients with low-back pain. Due to their educational background chiropractors have special skills in performing manual therapy including spinal manipulative therapy. in addition to examining a low-back patient provide information/advice and initiate treatment such as pain relieving medication or exercise therapy. Many physicians use or have knowledge of manual treatment. Due to the central role that the general practitioner plays in the health care system he/she is in a position to prevent “double” examinations and treatment regimens. The general practitioner can. The general practitioner has all relevant information regarding previous illnesses as well as reports from hospital treatments.
prescribe exercise. or chiropractor or certain patients suffering from acute or chronic low-back pain should be referred to specialists for further evaluation such as CT-scans – refer to Low-Back Pain Volume 1. The specialist in the primary health care sector Different medical specialists in the primary health care sector evaluate patients with low-back pain.portant treatment elements utilised by chiropractors include information/advice. Psychologists Psychological evaluation and advice undertaken by authorised professionals can be relevant in certain cases. Specialists also provide individual information/advice. the patient is recommended to see the general practitioner. Physiotherapists oftentimes carry out manual treatment particularly mobilisation and supplemental soft tissue treatment. Unauthorised health care provider in the primary health care sector Traditionally. exercise instruction and intensive training. physiotherapist. Advice on preventive measures is also undertaken. Patients who have not experienced relief of symptoms after treatment at a general practitioner. The physiotherapist carries out functional examinations. which primarily undertake examinations and evaluations of low-back patients. Physiotherapists inform patients about the illness and prognosis and can advise/inform patients regarding preventive measures. Some physiotherapists use spinal manipulation. The physiotherapist in the primary health care sector Physiotherapists are authorised by the health authorities and upon referral from a physician can treat low-back pain patients in conjunction with the general practitioner or hospital physician. are rheumatologists and orthopaedic surgeons. The medical specialities. other health care providers treat patients with low52 . and effectuate manual treatments. Patients receive reimbursement from the health care system. If the chiropractor ﬁnds consideration for it. designs training programs and instructs in exercise therapy. Soft tissue treatment is also used but is not a mainstay of treatment. It is not customary that patients consulting psychologists because of low-back pain receive reimbursement from the health authorities. In addition they carry out follow-up status reports of patients and evaluate whether further treatment should be carried out.
They co-operate with health care professionals particularly in assisting with patients’ maintaining their connection to the job market in periods of long-term sick leave. Other reasons for referral may be for special treatment forms such as rehabilitation or spinal surgery. mobilisation and training. accident and work-related compensation and/or disability pensions. The individual treatment is based upon an analysis of the body at rest and in movement as well as the patient’s psychological and social situation. zone therapy and dietary advice. Group sessions can be carried out under the “law of public information” at evening school sessions. neurosurgeons. The Work Environment Institute participates in the preventive and advisory work areas at individual work places. Referrals to hospital departments are most commonly due to a request for imaging studies such as CT or MRIscans. Other forms of training/gymnastics (for example Mensendeck) are provided by unauthorised individuals. This may include rheumatologists. orthopaedic surgeons. a general practitioner or a specialist will refer patients to a hospital department where several different medical specialities may be involved in the evaluation of a patient. as is alternative treatment such as acupuncture. Hospital ambulatory/departments In certain situations. Case management should be carried out in close co-operation with health professionals and only after medical evaluations and reports have been retrieved. Hospitalisation in order to provide relief from daily activities can be necessary in special cases such as when patients cannot take care of themselves at home. 53 . Information and instruction are integral parts of the treatment regimen. Other players in the primary health sector care Social workers employed by the local municipality and the Workman Compensation Board are important players regarding the low-back pain issue in the primary health sector. Treatment at relaxation therapists involves manual treatment of the musculature. Other important areas include participation in the determination of the degree of work disabilities.back pain in the primary health care sector. and insurance companies play an important role when accidents have taken place. neurologists. or radiologists. The relaxation therapist can carry out individual treatment regimens in private practice or in group sessions.
Health professionals in the primary health care sector should co-operate in a close fashion for example. by exchanging journal information. There is also a great need 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 on low-back patients in the present as well as the future. Patients should only be referred to the secondary health care sector in certain situations. These courses should also include representatives of the social services. x-rays and treatment results. The examination and treatment strategy design in the secondary health care sector is multi-disciplinary and should be carried out in an ambulatory fashion as far as possible. These quality control instruments must become a part of daily procedures in the primary health care sector. A smooth and well functioning treatment system is dependent upon all health professionals being aware of the educational background and professional capabilities of all other authorised health professionals. The information given to patients should also be the same regardless of who evaluates. informs and advises the patient. Inter-disciplinary and inter-sector courses and professional development should be strengthened. Volume 1. 54 . This will limit unnecessary illness behaviour and resource waste. In order to insure the fulﬁlment of these goals and treatment quality it is necessary to develop inter-disciplinary “low-back pain” reference programs and quality control systems in the form of nationwide databases. Results of x-rays and scanning reports should be provided in a manner such that relevant information follows the patients throughout the treatment sector. More detailed information is provided in Lowback Pain. Treatment regimens should be the same regardless of whether a patient consults a general practitioner or a chiropractor.OPERATION BETWEEN HEALTH CARE PROVIDERS The treatment of low-back pain patients should to the degree that it is possible be carried out in the primary health care sector and preferably in the area where the patient lives. Special diagnostic examinations such as CT or MRI-scans should be carried out in close co-operation between the primary and secondary health care sectors in accordance with an overall priority plan.CO .
discomfort or anxiety? Social effects Are daily activities effected? Is the ability to work effected? Ethical aspects Is the patient willing to accept the technology? Is it acceptable for society? 55 . which was made up of systematically chosen elements which when combined represent the HTA evaluation of the singularly analysed technology.2 The LPB-group’s analytical method HTA. The blueprint includes the following: THE TECHNOLOGY The area of utilisation What 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? Effectiveness What documentation is there for its effectiveness? Is it more effective than other technologies? Is it as effective in our population? Risk evaluation Are there side effects? Are the potential side-effects reasonable compared to the potential clinical effect? THE PATIENT Psychological status Does the technology result in comfort.BLUEPRINT Our analyses are based upon a systematic review of material.
In several situations we did not use all of the individual elements of the blueprint because it would have been irrelevant. nursing help at home. county. including: side effects. transportation. The blueprint was used by the panel as a “reminder sheet”. operations. or medicine? Indirect costs What are the indirect costs associated with the program such as sick leave and loss of productivity? Direct savings What are the direct savings associated with the clinical effect of the program? Indirect savings What indirect savings will result from the implementation of the program? We have assessed the division between the state.ORGANISATION Structure Should 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? Personnel Are 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? Environment Will the external environment be effected negatively? Is there a risk of a negative effect on the work environment? ECONOMICS Direct costs What are the direct costs associated with the program. municipality. In a few circumstances it was impossible to evaluate the technology in all aspects because we could not ﬁnd the necessary 56 . patient and others regarding all of the above mentioned savings/ expenses.
Generally. which support the usefulness of a particular technology. 3. 1. The commentary’s weight. the group arrived at a recommendation of either suggesting or not suggesting the usage of the individual technology. Firstly. It was impossible. Then we estimated the expected costs for the individual technology. T HE SCIENTIFIC DOCUMENTATION THAT WAS USED BY THE PANEL N The recommendations.which supports the usefulness of a particular technology 57 . which support the value of a particular technology. Strength A Strong research based documentation. the blueprint was a great help to the panel and it contributed to the systematic evaluation of the technologies. Scientiﬁc studies can sometimes support the usage of a particular technology and in other situations recommend that they are not used. Strength C Limited research based documentation such that there is at least one relevant medium quality study. Finally. which follow. to determine how often every technology is used in Denmark because there is no systematic registration of this type of data. are based upon scientiﬁc documentation and are ranked on a four-point scale. the quality of the scientific foundation for the usage of each technology was evaluated (with guidance from the international HTAreports). The commentary’s weight.information. 2. The commentary’s weight. such that there are many relevant high quality studies. The reader should be aware that a recommendation regarding a singular technology could either be positive or negative as regards its usage. for example. T HE PANEL’ S EVALUATIONS In order to assure that our evaluation process was systematic we developed a scale for the purpose of ranking each item. Strength D There is no research-based documentation. which support the usefulness of a particular technology. G RADING The commentary’s weight. Strength B Moderate research based documentation such that there is at least one relevant high quality study or several medium quality studies.
be that a particular treatment should only be used with certain diagnoses. This type of treatment is expensive. which can be carried out by the patient themselves. That is why we have supplemented each recommendation with additional commentary. An example of this commentary would. This type of treatment is not very costly HIGH COSTS A treatment that requires hospitalisation. 58 . MODERATE COSTS An ambulatory treatment which is carried out at a hospital or at a health professional in private practice.or 0 spines We wish to emphasise that even if a technology has received 2 spines we do not mean that it should be used in all circumstances. or in combination with other treatments. This type of treatment can as a rule be carried out at home or at work and does not involve expensive equipment or professional help.COSTS THAT ARE ASSOCIATED WITH THE UTILISATION OF THE TECHNOLOGY The next process involved direct cost calculations regarding each individual technology. No treatments are relevant in all situations. for a limited period of time. T HE PANEL’ S RECOMMENDATIONS The LBP-group concludes each treatment evaluation with one of the following recommendations: “Recommended” / “recommended for certain conditions” / “not recommended”. The numbers given are 2. for example.1. LOW COSTS Simple treatment or exercise.
which represents our recommendations. 59 . Mostly the reason for a method being “not recommended” is that there is insufﬁcient documentation for a positive effect in relation to the resources used for the method. that these methods of treatment should not be used. so that additional clariﬁcation will be presented. In these few cases it will clearly be noted in the text. Only in few cases have the LBP-group evaluated treatments as “not recommended” on the basis of documented evidence for direct harmful effects. the LBP-group will.The scale. in addition to providing the evaluations of “recommended” or “recommended for certain conditions.” provide explanatory commentary. In other cases the treatment can not be recommended. 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. because there is good evidence for the method being of no effect.
This may be due to the type of research design. indeed very effective for a sub-population of the large patient sample. Fifty percent will recover within three weeks. Passive treatment runs the inherent risk of promoting passive behaviour 60 . The typical course of acute low-back pain results in a spontaneous recovery for 60-80% of patients irrespective of treatment. or due to the possibility that the treatment in question is not effective in the remainder of the population sample or may in fact be harmful for them. N N N N It is difficult to arrive at a clear diagnostic classification for patients because the pathoanatomical basis for most diagnoses is questionable. It is precisely this factor. It is difficult to describe the content of the “tested” treatment because treatments are often individualised and reﬂect physical ﬁndings. ACTIVE OR PASSIVE TREATMENT One of the greatest errors in the treatment of low-back pain in this century has been the unquestioned usage of passive treatments. oftentimes initiated when spontaneous recovery has already begun. These factors can individually or in combination with one another result in it being difﬁcult to carry out a reliable scientiﬁc study and make it difﬁcult to interpret previously carried out studies.3 Treatment D OCUMENTED TREATMENT EFFECT Ninety percent of patients will recover spontaneously within 12 weeks after experiencing a ﬁrst-time episode of low-back pain. which necessitate stringent methodological needs in the design of scientiﬁc studies in determining the clinical effect of different treatments. Studies are designed to evaluate the general effect of a treatment on a large sample population. health professional can be difﬁcult to attain. In reality the treatment involved may be effective. The ideal “blinding” of the study group vs. There are also other methodological difﬁculties involved in the design of scientiﬁc studies dealing with “low-back pain”. This effect may not be “discovered” in the total population sample.
chronic? The total treatment strategy should be planned in accordance with the answers to the previous questions. Results of clinical research from the past ten years have clearly documented that pro-active treatment for both acute and chronic patients represent the most important factor for the continued effect of treatment.(illness behaviour) and thereby prolonging the course of illness. PATIENT INFORMATION The low-back pain patient has a need of comprehensive information regarding possible pathological mechanisms as well as the diagnostic possibilities or the lack thereof. A patient with a chronic condition – perhaps disabling – needs a more complex treatment strategy often made up of several elements. This however.acute. How great is the problem? How high is the level of pain intensity? Can the patient manage their work? How has the condition affected the individual’s ability to manage daily activities? How long has the condition been present. does not excuse health professionals for their inappropriate choice of treatment. The total amount of treatment should reﬂect the magnitude and duration of the presenting problem. Patients have to be motivated to participate in active care if it is to be successful. T REATMENT STRATEGIES Prior to determining the treatment strategy. A simple uni-dimensional treatment is rarely sufﬁcient. prognosis and treatment principles. This situation may lead to chronicity. The goal is therefore to design a treatment strategy that is individualised and addresses the differing areas of the problem. treatment is not usually necessary. This is most readily achieved if patients have been provided with comprehensive information regarding the diagnosis. The chosen treatment strategy should also be discussed thoroughly. The ordinary ﬁrst-time episode of low-back pain will usually resolve within a few days and besides advice regarding general lifestyle and physical ﬁtness. It is important to be aware of the multi-factorial nature of low-back pain. Prior 61 . Furthermore. the frequently benign nature of most episodes of low-back pain should be underscored. it is necessary to undertake an overall evaluation of the patient’s condition. Patients bear a degree of responsibility for the overuse of passive care because they have oftentimes requested or demanded it due to comforting factors.
EVALUATED TREATMENTS The most commonly used treatments for low-back pain will be addressed. The duration of treatment as well as eventual risks should also be reviewed. It is often important to carry out another information session 2-4 weeks into treatment in order to repeat the most important aspects of the treatment strategy. Treatments are listed in alphabetical order within each category. The following statements include the most important facts about “low-back pain” – as we know them. We begin with the treatments that can be recommended and follow with those that cannot be recommended. N N N It is not usually dangerous to experience low-back pain and work will only rarely worsen the condition. improved functional levels. 62 . work and so forth. the risk of never returning to work only increases. Treatment strategies for chronic pain patients necessitate the active involvement of both the health professional and the patient as well as co-operation between them. It is important to inform the patient that there are no miracle cures and that success is dependent upon sincere participation on the part of the patient. Long-term sick-leave will not improve the condition – on the contrary. A conversation with the patient regarding these central principles of illness and treatment cannot be completed in less that 20 minutes. T HE HTA .to beginning treatment patients should be made aware of goals regarding pain relief. It is almost always best to continue going to work even of there is pain present.
osteoporosis or joint displacement.It is not possible to predict which individuals will beneﬁt from manual treatment (B). or when the patient is suffering from serious and/or progressive nerve root irritation are examples of this.In addition to pain treatment indication is supported by the clinical observation of functional disturbances of the motion segments of the low-back or the joints of the pelvis (D). which contraindicate manual treatment in certain conditions. infection. myofascial release. This treatment is often combined with other methods such as soft tissue treatment and medication in the case of acute pain or exercise in the case of chronic pain. but also related techniques such as manual traction. With manipulation a motion segment of the spine is pushed beyond its normal passive range of movement by means of a thrust. Treatment is given in order to relieve pain and improve function. inﬂammation. 63 . Contraindications There are a series of factors. and muscle energy techniques. . Documentation . In situations where the low-back pain is determined to be of functional origin but where structural weakness of the bones or joints as seen for example with severe degeneration.4 Treatments which can generally be recommended TREATMENT METHOD MANUAL THERAPY Technology Manual therapy can be broadly deﬁned as all procedures where the health professional uses his/her hands in order to inﬂuence a joint complex as well as the surrounding tissues. Conditions in which the symptoms are a result of cancer. The procedures include manipulation and mobilisation. treatment should be appropriately modiﬁed.
There is evidence that manual treatment has a short-term effect on chronic low-back pain.Manual treatment has been investigated in a multitude of clinical studies and there is evidence that acute low-back pain episodes can be shortened with manual treatment (B). The development of cauda equina syndrome (nerve root pressure with bladder function impairment) has been described. . . Risk evaluation Manual treatment is generally a very safe treatment when relevant contraindications are addressed. but the literature is inconclusive about longterm beneﬁts. Serious complications are considered to be rare. RECOMMENDED Manual treatment can be recommended as an initial treatment for acute exacerbations of recurrent or chronic low-back pain and functional limitation . Approximately 25% of patients experience short-lived tenderness in the treated area.. 64 .There is limited evidence of a positive treatment effect with patients suffering from nerve root irritation (C). At present there is no evidence of the utility of continued manual treatment (B). Costs MODERATE COSTS Treatment is primarily administrated in the primary health care sector and is ambulatory Recommendations RECOMMENDED Manual treatment can be recommended for patients suffering from acute lowback symptoms and functional limitations of more than 2-3 days duration.
This change in attitude has resulted in improved preventive results Documentation . and so forth.There are several scientiﬁc studies. It is common to include instruction and practical guidance for exercise during back school sessions. spread over weeks to months. TREATMENT METHOD BACK SCHOOL / GROUP TRAINING / ERGONOMICS Technology The term “back school” implies providing information about the anatomy and function of the spine as well as advice on activities regarding prevention and self-treatment. which also includes exercise programs. lift correctly. . 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 into account the previously mentioned contraindications. In a modern back school the emphasis is to avoid fear.A “modern back school” where teaching has focused upon “igno- 65 . Oftentimes the theoretical instruction is an integrated element of a comprehensive course of back rehabilitation. avoid forward bending. The philosophy was guided by “be careful” messages. The total duration of the back school is approximately 4-6 hours. Back school programs are usually led by physiotherapists. sit correctly.RECOMMENDED FOR CERTAIN CONDITIONS Manual treatment can be considered as an element of a broader strategy for chronic low-back trouble. The integrated rehabilitation program is usually of 15-30 hours duration. The traditional back school has been evaluated in several randomised trials. such as. Teaching is carried out in group sessions. ergotherapists and relaxation therapists. which have not demonstrated any short or long-term effects from the “traditional back school” with low-back pain patients (B). and the philosophy is to “ignore the pain as much as possible”.
(From low costs to hign costs depending upon the type of course). As regards the ergonomics of sitting: Uncomfortable furniture should obviously be exchanged in order to achieve a more comfortable sitting posture. Costs MODERATE COSTS Ambulatory treatment. Relatively few lifts of light objects during the course of a days work will in all likelihood not increase the risk of injuring the spine and therefore do not require special precautions. However. It is important that individuals have the opportunity to “test” different types of furniture prior to purchase because factors reﬂecting sitting comfort and table height may be individual (C). Back school should include physical activity and promote attitudes which work against the development of chronic disabilities rather than “be careful messages” (B). HIGH COSTS Purchase of teaching aides/ergonomic materials.- - - - - ring the pain as much as possible” has demonstrated a preventive effect with patients suffering from low-back pain (B). have not been thoroughly investigated in a scientiﬁc manner and recommendations must therefore be guarded (D). such as the psychological environment of the workplace. As regards lifting technique: Objects should be lifted while “bending at the knees” as opposed to bending the spine forwards if the weight is more than 10-12 kilograms. Several scientiﬁc studies assessing prevention at the workplace have shown a reduction in sick leave due to low-back pain (B). Patients with a well-deﬁned need of rehabilitation such as post-operative disc herniation patients demonstrate a reduced likelihood of developing chronic symptoms after participating in back school/ rehabilitation programs (C). 66 . repeated lifting during the day – light or heavy objects – necessitates speciﬁc ergonomic instruction (D). Other areas of ergonomics not relating to sitting and lifting.
TREATMENT METHOD PAIN RELIEVING MEDICATION Technology Pain relieving medication is sold “over the counter” (without prescription) (for example paracetamol) or with a prescription if a higher dosage is required such as NSAID (non-steroid anti-inﬂammatory medication = pain relieving arthritic tablets).or when preventive efforts are being considered at work places where work tasks can be challenging for the low-back.There are no studies which document that utilising several medications at the same time results in additional beneﬁt (C). . It has not been determined whether paracetamol or NSAID is more effective (C).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. Stronger pain relieving medication such as morphine derivatives can also be utilised.There are no studies.Several studies have documented the effect of paracetamol. RECOMMENDED FOR CERTAIN CONDITIONS Individual ergonomic instruction – such as advice regarding sitting comfort and lifting conditions can be considered especially if repetitive lifting can be reduced. the risk of side-effects generally increases with the utilisation of several drugs (B).There are no studies. . . Documentation . however. NSAID and stronger analgesics for the relief of acute low-back pain (B). 67 . which document an enhanced clinical effect of morphine derivatives compared to either paracetamol or NSAID (C). which document any long-term effect of pain relieving medication for chronic low-back pain (C).
. Muscle relaxants such as Diazepam have no place in the treatment of low-back pain. There may be CAVE obstipation from codeine Individual considerations must be taken into account when using paracetamol and NSAID. . First step N Paracetamol up to full dosage If there is a lack of effect. Patients rarely experience beneﬁt of pain relieving medication for more than a month or so (1-3 months). If there is use a stepladder approach.There is a risk of both physical and psychological dependence when using morphine derivatives after as short a time as a few weeks (B). Stronger medication (morphine derivative) should only be prescribed for relatively short periods of time (max. go to the next level: N A combination of paracetamol and NSAID If there is a lack of effect. If patients have sleeping difﬁculties. Costs LOW COSTS Recommendation RECOMMENDED Evaluate if there is in fact a need of pain relieving medication. after surgery. These medications should only be used in periods of severe acute pain. The possible clinical beneﬁt is overshadowed 68 .Several studies have shown that a singular medication may result in a varying effect upon differing individuals (B). sleeping pills in addition to pain relieving medication can be used for a short period of time. or if the abovementioned principles have been ineffective. go to the next level: N NSAID up to full dosage If there is a lack of effect. go to the next level: N Tramadol or codeine in conjunction or as a monotherapy (evaluate individually). Increase the dosage after 1-2 days if there is a lack of effect from the initial medication . 1-2 weeks).
Documentation There are a few studies. A few studies indicate a positive clinical effect with patients suffering from chronic low-back pain (with or without radiating symptoms) (C). and an advantage of these exercises is that patients assume responsibility for carrying out their treatment and are therefore activated. which show a positive clinical effect with patients suffering from acute low-back pain (with or without radiating symptoms) (C).by the risk of physical and psychological dependency even after short periods of usage. Programs are designed according to the “preferred” movements and patients are instructed to carry out their individual programs up to several times per day. 69 . Costs LOW COSTS Home treatment. TREATMENT METHOD EXERCISE THERAPY ACCORDING TO MCKENZIE Technology as a form of treatment The background for this exercise program is that movements in the low-back can either increase or decrease patient symptoms. MODERATE COSTS Ambulatory treatment. but most of them are methodologically weak. The therapist can guide patients as they repeat certain movements until they ﬁnd the movement which either reduces symptoms or centralizes them (distal pain moves centrally toward the vertebral column). There is little risk of side effects for patients. There are several studies. which have investigated the McKenzie method.
discogenic pain) (B). improving joint movement and body 70 . The McKenzie Technology as a diagnostic method When patients repeat a speciﬁc movement the preferred type of movement can be determined. TREATMENT METHOD EXERCISE THERAPY / FITNESS Technology The therapy consists of a series of speciﬁc movements with the goal of increasing muscle strength. Documentation . Costs MODERATE COSTS Home treatment. This is therefore a useful diagnostic instrument for low-back patients in which the pain source is one or more discs in the low-back.Several studies indicate that the method has value as both a diagnostic tool and a prognostic indicator (+/. Recommendation RECOMMENDED This technique can be recommended as a diagnostic method for both acute and chronic pain syndromes.Recommendation RECOMMENDED FOR CERTAIN CONDITIONS McKenzie exercises can be considered as a treatment method for both acute and chronic low-back pain.
It is important that patients maintain or improve their physical condition through training after the acute pain has resolved (B). 71 . The expectation is that the exercise therapy/ﬁtness will improve movement restrictions.Several studies document that a high dosage exercise (twice a week for a period of 2-3 months) is an effective treatment for chronic low-back pain (B). Documentation for the usage of the technology with acute low-back pain patients . improve functional levels and reduce pain. Costs LOW COSTS Home exercises. Exercise therapy/ﬁtness can be particularly effective in increasing tolerance for physical activity and illness behaviour in chronic low-back pain patients.Patients with chronic low-back pain who have psychological problems and are at risk for losing their contact to the work force can in certain situations have additional beneﬁt from a combination of training/ergonomic instruction/psychological intervention (D). There are only a few studies in the literature which deal with this issue (C).should begin after 6 weeks of continued low-back pain and reduced mobility (B).There are studies. . Patients that are encouraged to remain as active as possible during the acute phase seem to do better that those patients performing a series of speciﬁc exercises. Documentation for the usage of the technology with sub-acute lowback pain patients (from 6 weeks to 3 months) .co-ordination by carrying out a systematic training program. Documentation for the usage of the technology with chronic lowback pain patients . which indicate that back exercises of certain intensity – according to therapeutic instruction. .There is no evidence that speciﬁc exercises introduced in the acute phase of low-back pain will shorten the duration of the episode.
RECOMMENDED FOR CERTAIN CONDITIONS Can be considered as a preventive effort for patients who have experienced several episodes of low-back pain. 72 .MODERATE COSTS Ambulatory treatment. Recommendations RECOMMENDED The treatment can be recommended for patients suffering from low-back pain for 6 weeks or more.
Anaesthesia (local anaesthetic) d. 73 . JOINTS .c. Combinations of b. near nerve tissue for example in a joint cavity. AND LIGAMENTS AND IN CLOSE APPROXIMATION TO NERVES . Acupuncture can be performed by unauthorised health workers provided that it is done under medical supervision. Relief of pain may provide evidence that the site of injection was in fact the source of pain. Treatment can involve/use any of the following: a. The most common combination is an anaesthetic + steroid usually in a combined volume of 5-10 ml.in soft tissues for example in “trigger points” = special pain centers (muscles). Phenol g.5 Treatment methods that can be recommended in certain conditions TREATMENT METHOD INJECTIONS IN THE MUSCLES . or an epidural injection in the spinal canal. ligaments. Hypertonic salt water c. fascia. INCLUDING ACUPUNCTURE Technology The term injections is meant to include the injection of liquid or acupuncture needling -dry needling. Steroids e. Usually a single injection is performed but there may be a need of 1-2 repetitions during the course of a month. The time interval between injections is dependent upon the liquid injected as well as the volume. The total number of injections should not exceed 3. Dry needling/acupuncture b. bursae. in joints.or d. Injection treatment can be carried out in order to provide relief or as a diagnostic measure. NSAID f.
000) a serious complication can take place in the form of a local infection around the area of the injection.There is limited and non-conclusive research based documentation regarding the diagnostic or clinical value of injections for acute lowback pain (C). Due to this we advise that injection treatment be combined with patient activating strategies. Repeated injections with steroids involve a risk of serious systematic side effects. . Repeated injections increase the risk of passivity and illness behaviour on the part of the patient and we therefore recommend extreme caution. The risk of infection depends upon the content of the injection. TREATMENT METHOD INJECTIONS IN TRIGGER POINTS . Injection with phenol is not recommended due to the fact that permanent damage to the skin and connective tissue in the area of injection may take place.There is limited research based documentation for either the diagnostic value or short-term clinical effect with chronic low-back pain and no documentation of long-term effects (C). Costs MODERATE COSTS 74 .Side-effects Occasionally (less than 1 out of 10. MUSCLES AND LIGAMENTS Documentation .
Recommendation RECOMMENDED FOR CERTAIN CONDITIONS Facet joint injections cannot be recommended as a treatment but they may be considered as a diagnostic procedure in certain situations.There is no documentation of any clinical effect of injecting the sacroiliac joints. 75 . Recommendation RECOMMENDED FOR CERTAIN CONDITIONS Facet joint injections cannot be recommended as a treatment but they may be considered as a diagnostic procedure in certain situations. but there is some documentation for the utility of this method as a diagnostic tool (C).There is only limited scientiﬁc evidence of any clinical effect regarding acute or chronic low-back trouble (C). Costs HIGH COSTS The treatment is carried out in an ambulatory manner at hospitals with imaging guidance. . TREATMENT METHOD FACET AND SACROILIAC JOINT INJECTIONS Documentation .
TREATMENT METHOD EPIDURAL INJECTIONS Dokumentation . There is evidence of a risk of rare but serious complications from injections (A).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 radicular symptoms (C).There is a limited amount of research based evidence for a shortterm pain relieving effect with acute or chronic low-back pain patients but no evidence of any long-term effect (C). Costs HIGH COSTS Recommendation NOT RECOMMENDED TREATMENT METHOD ACUPUNCTURE Documentation . .There is no evidence of any clinical effect with acute low-back patients without radiating symptoms or with chronic low-back pain patients (D). Costs MODERATE COSTS 76 .
TREATMENT METHOD MASSAGE AND HEAT / COLD THERAPY Technology Soft tissue treatment.There are a few studies. exercise therapy and so forth. Costs LOW COSTS Home treatment. which demonstrate a short-term pain relieving effect but no long-term effects (B).Recommendation NOT RECOMMENDED We do not recommend that acupuncture be used for low-back pain patients because the possible clinical beneﬁts do not outweigh the costs and eventual risks. Documentation: . 77 . Recommendation RECOMMENDED FOR CERTAIN CONDITIONS We do not recommend this treatment generally but it can be considered for pain relief for localised muscle pain or for initial pain relief/relaxation prior to using other documented treatment methods such as manipulation. which increases blood circulation or decreases tension. MODERATE COSTS Ambulatory treatment .
There is a lack of prospective controlled clinical trials for all of the procedures mentioned. Disc herniation The technique used for performing ﬁrst-time or repeat surgery for disc herniations is well known and requires low-tech equipment. Local and regional organisational factors determine which medical departments perform the different procedures described. There can of course be situations where a combination of the above mentioned procedures or indeed all of them may be involved. 78 . In the text that follows operation types are grouped into three main categories. Operation for spinal instability. This report will not deal with all of the different operative methods involved for example in treating fractures or different anomalies of the spine such as scoliosis: A: B: C: Operation or re-operation for a disc herniation. The procedure is carried out by means of a partial laminectomy (hemilaminectomy).TREATMENT METHOD BACK SURGERY The technology There are several different operative methods as well as operation types for differing conditions in the back. Dominant leg pain will more frequently result in surgical intervention than low-back pain alone. A repeat surgery is essentially the same procedure but more bone tissue is removed prior to removing scar tissue. Both neurosurgeons and orthopaedic surgeons perform the above mentioned operations. Operation for spinal stenosis (narrowing of the spinal canal). Operations are rarely performed purely on the basis of low-back pain but more often due to low-back pain with radiations to the leg or legs. & C) performed in Denmark number approximately 4.000 per year. The total number of surgeries (A. B. The important developments in spinal surgery necessitate that both of the medical specialities involved need to co-ordinate their activities to a greater degree so that patient selection and chosen operative techniques in all regions are conducted according to a common consensus. A small amount of bone tissue is removed and the exposed nuclear and disc tissue is removed.
Documentation: . Costs HIGH COSTS 79 . In addition there has to be a positive correlation between clinical ﬁndings and imaging reports. However. Acute operations (within hours or days) are carried out if there are signs of cauda equina syndrome.There are many relevant but uncontrolled studies. Subacute operations may be performed if a patient is experiencing progressive weakness in the leg during the course of a few days or if the pain is extremely severe in spite of medication. . The risk of serious complications is rare (A). In addition to the described operation technique other techniques such as microsurgery (involving a microscope) may be used. In the counties that have departments of neurosurgery operations are primarily carried out at these departments. This type of surgery has not demonstrated shorter post-operative hospitalisation stays. It seems as though microsurgery results in a greater number of relapses. these procedures are also carried out at orthopaedic departments particularly in counties in which there are no neurosurgery departments. which demonstrated a long-term effect on pain after surgery. Commentary Three thousand operations of this type are performed per year.Indication First-time surgeries are not usually performed before conservative therapy has been attempted for 4-6 weeks.Success rates are in the range of 70-90%. Only a single randomised study compared the results of operations to conservative care (C).
The diagnosis is made with MR-scans or with functional myelography eventually supplemented with CT-scans Indications There must be a clear correlation between long-term functional disturbances.Recommendation RECOMMENDED Surgery can be recommended provided that the above mentioned criteria are present.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). . Approximately 300 are performed per year.There is scientiﬁc documentation as regards pain relief in 60-70% of patients when the previously mentioned criteria are present (B). Dokumentation . This procedure involves a more comprehensive removal of bone tissue and nerve decompression than disc herniation procedures. TREATMENT METHOD SPINAL STENOSIS Procedures for spinal stenosis involve well-known and low-tech instrumentation. Commentary These operations are carried out at either neurosurgery or orthopaedic departments. objective clinical ﬁndings and imaging results before considering this procedure. Costs HIGH COSTS 80 .
the symptoms. In order to determine whether there is a clear indication for surgery there has to be a clear correlation between the history.Recommendation RECOMMENDED FOR CERTAIN CONDITIONS This procedure can be recommended in certain instances if the previously mentioned criteria are present. Commentary Five to six hundred patients undergo this procedure each year. This operation (3-8 hours) is much more invasive that the previous procedures. Patients will oftentimes have undergone operations for disc herniations or spinal stenosis. myelography and CT-scan. The radiological examination procedures are also considerable. the objective examination and the imaging results. TREATMENT METHOD STABILISING BACK SURGERIES Stabilising back surgeries require more operation equipment. and bone transplant material (preferably from the patient or from a bone bank). This may help in determining whether a “stiffening” operation will be helpful. MR-scan. Pain may be due to instability or painful movement. This procedure is therefore both a low and a high-tech procedure. Indications The surgical candidate must undergo a comprehensive examination program possibly involving a test period during which he/she wears a corset. Particularly long lasting operations may require blood transfusions. metal for ﬁxation. Twenty to forty per cent of patients require additional surgeries because of a lack of healing of the bones. This type of operation results in more complications than the previously discussed procedures and complications may be of a very serious nature. specialised tools. 81 . In addition to plain x-rays one or several of the following examinations may be involved.
Costs can run up to 80-100.This type of operation should be performed in a few centres only and in close co-operation between neurosurgeons. This procedure is still in a developmental stage and more controlled studies need to be carried out.There is no clear scientiﬁc documentation for pain relief or functional gains. Commentary Work is going on to deﬁne more certain operation indications and prognostic factors.000 DKK per operation. orthopaedic surgeons and rheumatologists. Costs HIGH COSTS Recommendation RECOMMENDED FOR CERTAIN CONDITIONS This procedure can only be recommended in particularly well chosen cases in which the patient has clear surgical indications. TREATMENT METHOD BED REST The technology In cases where there is a suspicion of disc herniation bed rest (23-24 hours per day) is carried out in order to unburden the back. The uncomplicated cases can be operated on in smaller centres in co-operation with major centres. 82 . There is empirical evidence that states that 50-70% of all patients experience beneﬁt if the previously mentioned criteria are present (D). Documentation .
bed rest can be considered as a pain relieving measure for a maximum of 1-2 days.There is empirical evidence that patients who are suspected of suffering from disc herniations will beneﬁt from bed rest of up to one week’s duration.If patients are suffering from severe pain. This beneﬁt can result in long-term pain relief for some patients (D). Costs LOW COSTS Home treatment. Recommendation NOT RECOMMENDED Bed rest for patients not under suspicion for disc herniation should be discouraged.There are several studies dealing with this treatment but results are unclear.Documentation . 83 . TREATMENT METHOD TRANSCUTANEOUS NERVE STIMULATION The technology . .There is evidence that even a few days of bed rest for patients where there is no suspicion of disc herniation increases functional loss and enhances the likelihood of chronic symptom development (B). HIGH COSTS Hospitalisation. Some studies demonstrate an apparent pain reduction in patients suffering from chronic symptoms (B).
It can be considered in certain patients suffering from chronic pain.Costs LOW COSTS Home treatment. Recommendation RECOMMENDED FOR CERTAIN CONDITIONS We do not recommend this treatment as a commonly used procedure. 84 .
Costs LOW COSTS Recommendation NOT RECOMMENDED Cannot be recommended.6 Treatments that cannot be recommended TREATMENT METHOD CORSETS The technology Specially sown material corsets or soft material belts. TREATMENT METHOD TRACTION The technology: This treatment is carried out with an apparatus. which stretches the back as well as the paraspinal structures. Documentation: .A positive clinical effect has never been demonstrated and there is little scientiﬁc data (D). 85 .
SHORT . Recommendation NOT RECOMMENDED We do not recommend this treatment for low-back pain with or without sciatica. There is no documented clinical effect (A). These studies do not indicate a clear clinical effect of traction with either acute or chronic patients with or without sciatica (A). There is a risk of symptom exacerbation in rare circumstances TREATMENT METHOD ULTRA SOUND. HIGH COSTS Hospitalisation.Documentation . LASER . Costs MODERATE COSTS 86 .WAVE THERAPY The Technology Soft tissue treatment with ultra sound/laser/short-wave therapy. Costs MODERATE COSTS Ambulatory treatment.There are approximately 20 studies of good scientiﬁc merit. Documentation: Several studies have been carried out.
Recommendation NOT RECOMMENDED These therapies cannot be recommended. 87 .
social and cultural factors in different societies will greatly effect the manner in which the individual patient as well as society at large will perceive concrete prophylactic projects. Secondary/tertiary prophylaxis refers to interventions for individuals who have already suffered from low-back pain. information campaigns to the general public about how to react to an episode of acute low-back pain and so forth. This makes it difﬁcult to determine how prophylactic measures in one society will work in another. N As the case has been for international consensus reports dealing with the area of prevention/prophylaxis our group has been unable to ﬁnd sufﬁcient data to undertake an HTA-evaluation of the individual measures. which is the focus of the intervention. Due to the same reasoning we will NOT grade the individual intervention’s strength. This chapter will therefore summarise the most important areas that should be focused on. 88 . Examples of primary prophylaxis include ergonomic changes at home or at work. The literature on prevention is sparse. In addition. advice regarding physical activities. or reducing the effects of poor health or reducing the social costs of already existing low-back pain so that chronic disabilities are prevented (tertiary prophylaxis). The effort is primarily aimed at preventing a reoccurrence of symptoms (secondary prophylaxis). The scientiﬁc evidence regarding proven prophylactic interventions is not strong. Primary prophylaxis is deﬁned as interventions for people who have no low-back symptoms either at the present time or in the past and who have no identiﬁable risk factors.7 Prevention The most important elements in the design of effective preventive efforts have already been mentioned in this report. Prevention can be divided into two different “areas of effort” which are deﬁned according to the group.
P RIMARY PREVENTION
Primary prophylaxis is often seen in public information campaigns, in which the public at large is warned about improper behaviour. These campaigns have rarely shown their effectiveness. A short-term information campaign has no long-term effect on the health attitudes/ behaviour of the general public. Only back school carried out at work places (page 66) has demonstrated a preventive effect as regards sickleave due to low-back pain . Ergonomic interventions have only demonstrated a marginal effect in several scientiﬁc studies. A reduction in the frequency of heavy and repetitive lifting and the elimination of inappropriate work stations (page 66) can have a certain effect on the frequency of future episodes of low-back pain. When workers feel “comfortable” it is doubtful that further ergonomic intervention will result in any meaningful gains. It is therefore most important to weigh any possible intervention with possible beneﬁts. It is therefore important to regard most “general” ergonomic initiatives as being geared to improve the job satisfaction rates of workers rather than an effort to actually reduce sick leave due to low-back pain. In other words: Ergonomic improvements can have a great effect on the comfort levels or workers without reducing sick leave. We recommend that future primary prophylactic initiatives focus upon the avoidance of clearly inappropriate work situations such as the elimination of very heavy or repetitive lifting, or sudden unexpected movements which can stress the back. This may reduce the number of accidents and other work-related injuries. Other ergonomic projects such as the changing of all non-adjustable writing desks to desks which can be adjusted in height have a primary goal of improving comfort as opposed to reducing the number of work related injuries and accidents. The economic priorities related to differing prophylactic interventions should be based upon realistic expectations as regards possible meaningful results. We must be aware of the fact that information campaigns with slogans such as: “4 hours of physical activity a week”, or “10 minutes of exercise at every break”, or “an hour a week at a ﬁtness centre” and so on have not demonstrated any short or long term effect. Experience tells us that individuals who are not ill are not motivated to participate in preventive activities. There is also the risk of a counter productive effect from messages of this sort. It is important that the central messages of information campaigns are not moralising. Information
should be presented in a neutral fashion such as explanatory information about the function of the back, examination techniques and available treatments. Advice about how future patients should tackle their ﬁrst episode of low-back pain would also be helpful. This type of message does not demand something of the individual in the immediate future such as doing something that will promote health but rather increases 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.
One of the most important goals of this type of prophylaxis is to prevent an ordinary acute episode of low-back pain from developing into a chronic and disabling low-back condition. Many risk factors can contribute to the development of chronic pain in the 10-15% of people with acute low-back pain that develop chronic symptoms. Particular factors such as long-term sick-listing, psychological stress or depression, and poor job satisfaction play important roles. See Low-back Pain vol. 1 pages 26-28. In the future it is important that the average course of treatment addresses these known risk factors in order to decrease the likelihood of chronic pain development. In order to reduce illness behaviour double treatment should be avoided. It is also important to reduce waiting times for examinations and treatments. Patients risk developing chronic symptoms while simply waiting for further treatment or examinations. We refer to Low-back Pain vol. 1 page 43. Lastly, we must make sure that patients are provided with thorough information about their condition, treatment, prognosis, and prevention so that uncertainties and anxiety levels are reduced. An important area which should be focused upon is providing special rehabilitation programs for patients who have experienced long-term low-back pain or serious disabilities regarding the ability to manage daily activities, so that functional capacities can become normalised or at least as good as they can be. Studies show that rehabilitation programs for patients who have undergone disc surgery insure that a larger number of patients return to a normal level daily functioning at their jobs and at home than if a rehabilitation program is not completed. Further research is still necessary in order to identify the most important secondary/tertiary efforts where the effect of the intervention is greatest related to associated costs.
S OCIAL ASSISTANCE PROGRAMS
An area, which requires additional focus, is the co-operation between health professionals, the social sector and the work place. The opportunity to return to work in a ﬂexible manner such as short or long-term “protected jobs” is important in order to secure that individuals suffering from severe acute pain can maintain their jobs. The rehabilitation of injured workers should also be co-or dinated by the abovementioned sectors. It is important that all relevant social services are utilised when needed 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 primary role in the co-ordination of continued treatment (see page ??).” Every individual county should take the initiative to develop and maintain close co-operation between all professionals involved. In order to secure that all relevant social services are provided to individual patients, it is necessary to have procedures clearly delineated. The previously mentioned secondary/tertiary prophylactic measures may appear to be rather obvious. However, they are not carried out in reality because the health care sector cannot offer the necessary rehabilitation and work hardening programs due to a lack or co-ordination between the different players and due to a lack of resources.
The content of treatments differs.8 Economics We mentioned several of the difﬁculties in calculating the total costs to society of low-back pain in “Low-back Pain.1” that the total yearly costs related to low-back pain was approximately 10 billion Danish DKK of which 3 billion DKK were direct costs and the remainder indirect costs. the state or the patient. The reader should be warned against comparing the cost of one type of service with another and thereupon concluding that funds can be saved if we always utilise the least expensive service. In order to simplify the problem costs are based upon a typical 4-week examination and treatment course in which a particular examination and treatment activity is carried out. Lastly. In the Appendix we have attempted to clarify the costs associated with different treatments for the individual patient that are typically offered in the health care sector. How much does it cost to carry out a x-ray examination. Vol. Vol. Treatment types are rarely comparable. 92 . the commune. We point out whom it is that pays for treatment. There is a lack of clarity about the total treatments provided in both the primary and secondary health care sectors. COSTS OF THE SINGULAR ACTIVITY It is easier to calculate treatment costs than total costs to society. 4 weeks of pain relieving medication treatment is much cheaper than a 4-week course of treatment at a physiotherapist or a chiropractor. We calculated in “Low-back Pain. Note that we have chosen typical and common examination and treatment courses but one can easily imagine many other equally typical courses. For example. 1”. Different methods of calculation result in different conclusions. Should one include the costs of maintaining a x-ray unit or building costs? What about heating the premises? It is difﬁcult to separate singular costs out of the total costs of running a department because many different activities take place in the same area by the same personnel. it is difﬁcult to calculate many of the individual services. as do patient needs.
Patients receive compensation (in the table we have used 50%). Pay during sick leave is paid for by the employer. 93 .Calculations should primarily serve to provide us with an overview of the costs associated with an individual course of treatment and which extra costs can be incurred if inappropriate treatment is begun. Hospital treatment is completely paid for by the county. B OX ECONOMIC ANALYSIS OF A COURSE OF TREATMENT FOR “ LOW . public employers. Private employers pay for the ﬁrst 2 weeks of sick leave while the remaining sick leave period is paid for by the commune in which the individual resides. Treatment at a relaxation therapist is not subsidised by the public health care system and payment is therefore made by the patient alone. Public employers pay for the entire sick leave period. In other words a view of which boxes ﬁnance the given examples of health services for patients with back pain. Employers who continue to pay full wages under sick-leave are entitled to receive the support that the commune would have paid to the employee during the sick-leave period. As regards support for privately practising physiotherapists and chiropractors support from the public health care system is 40% and 30% respectively. Medication is partially subsidised.BACK PAIN ” The table on page 94 contains a so-called box-economical analysis. On the other hand a consultation at a general practitioner or a specialist is fully paid for by the public health care system. and the commune. The state refunds 75% of the costs incurred by the commune for sick-leave wages.
964 7. We preclude that surgery has been successful and that the patient returns to work in good health. Upwards of 10.440 1. The examples are typical of long-term treatment courses. Vol.200 24. 1998.expensive Relaxation therapist Hospital treatment 2 weeks of hospitalisation for a disc herniation operation Ambulatory treatment PAYMENT OF SICK-LEAVE BENEFITS***) Sick-leave beneﬁts *****) *) **) ***) ****) *****) County Public health insurance 396 576 221 907 28 98 0 0 0 0 Hospital sector 0 0 0 0 0 0 0 24.Examples of treatment courses and the division of boxes of typical services in DKK 4 WEEKS OF TREATMENT IN THE PRIMARY HEALTH CARE SECTOR: Cost categories General practitioner *) Physiotherapist in private practice **) Chiropractor in private practice **) Medical specialist **) Medicin .141 0 0 672 2.964 7.246 17. Patients are typically sick-listed for 4-12 months in conjunction with treatment for disc herniations. S AVINGS IF “ RECOMMENDED TREATMENT COURSES ” ARE CARRIED OUT In order to arrive at the possible economic savings attainable if we strive to carry out desired treatment courses. The office of the Department of Health Insurance.104 0 28 98 1. We have calculated the direct costs as well as the costs associated with sick-leave beneﬁts.246 17.000 patients per year are treated for acute low-back disc herniations for shorter or longer periods of time. Per week. Some communes subsidise treatment costs. Conservative treatment is successful in the majority of patients but surgery is necessary for 25-30% of patients. On the precondition that sick-leave benefits are paid entirely by the commune whereupon the state refunds 75% of the costs. Århus County.325 907 56 196 1. In both of the “constructed” cases conservative treatment has failed and surgery has followed.141 Municipality 0 0 0 0 0 0 ****) 0 0 0 The state 0 0 0 0 0 0 0 0 0 0 Patient 0 864 1. For an example we have chosen treatment of an acute lowback disc herniation.inexpenive .200 0 0 0 In total 396 1. the LBP-group has constructed 2 typical treatment courses. Schultz Information.016 0 2.688 From the Department of Health Insurance. Schultz law service – Health laws. 1 many acute episodes of low-back 94 . As described in Low-back Pain.
95 . We assume that many more than the 10. The recommended course Patients receive treatment in the primary health care sector. There is no effect of the hospital treatment but treatment is carried out without wasting time. Due to a lack of improvement the patient is hospitalised on two different occasions for further examination and treatment. There is considerable waiting time both for the CT-scan as well as for surgery. rehabilitation will be necessary for a longer period of time than in the desired course of treatment due to the fact that the physical state of the patient is relatively worse after surgery and the many months of waiting. In this example. There is insufﬁcient communication between the health professionals and unnecessary waiting times develop. As there is no effect from the administered treatment the patient is referred to the spine center of the hospital.000 disc herniation patients go through similar courses of treatment as we described. Only the necessary health professionals are involved and there is good communication between them and no unnecessary waiting time. and a CT-scan was ordered. much treatment and the occasional hospitalisation. The non-recommended course The patient is examined and treated by several health professionals in the primary health care sector. The exact number is impossible to present. A physiotherapist or chiropractor carries out the treatment in association with the patient’s general practitioner. The ﬁrst hospitalisation was of 2 weeks duration during which conservative treatment was attempted without clinical results. waiting times for a CT-scan are approximately 3 months as are waiting times for surgery. surgery and rehabilitation (also without undue waiting time).pain (including those without disc herniations) lead to long-term sicklisting. This is followed by a CT-scan. At present.
The Figure. illustrates the two different treatment courses plotted against a time axis. Phys. Phys. Chiro. TR EATMEN T FOR DIS C HE RN IAT IO N The desired course SICK-LISTED General pract. Chiro. which follows. Waiting time Hospitalisation Waiting time Operation Rehabilitation Healthy ANALGESICS/NSAID 0 4 Time axis/weeks 8 12 16 20 24 28 32 36 40 44 96 . Waiting time Medical spec. The recommended course ends with a discharge after 20 weeks while the non-recommended treatment course ends with a discharge after 44 weeks. Back center Operation Rehabilitation Healthy ANALGESICS/NSAID 0 4 Time axis/weeks 8 12 16 20 The undesirable course SICK-LISTED General pract.
In total 169.7. are paid 9.Rehabilitation (alternative 1) 2.000.246.First hospitalisation 24.Medical specialist 907.390.Physiotherapist 1.17.310.1.- Costs associated with the “undesired treatment course” (in DKK): General practitioner 384.COSTS As we can see from the following calculation the “undesired treatment course” is more than twice as expensive to carry out as the “desired treatment course”. Patients in the “desired treatment course” in all likelihood experience a greater degree of patient satisfaction.772.964.Chiropractor 1.Hospitalisation and operation 17. who have not been helped by treatment and must leave the work force.53.647.83.008.325.000.000 DKK. who receive the middle level of pension. which results in a yearly cost of 110. Due to the uncertainties associated with loss of productivity we have included the costs associated with sick-leave beneﬁts instead.272.Inexpensive + expensive medication 22.214.171.1240. our calculations only relate to economic costs.964. Costs associated with the “desired treatment course” (in DKK): General practitioner Physiotherapist/Chiropractor (average) Back center Hospitalisation and operation Rehabilitation (alternative 1) Inexpensive + expensive medication Sick-leave beneﬁts *) In total 384. One should also include the costs associated with disability pensions for patients. 97 .Sick-leave beneﬁts *) 118. However.*) In an economic analysis one should also include production loss in conjunction with sickleave.2. Patients. There is a greater chance of achieving a complete cure and maintaining work capabilities for these patients as well. Should an individual receive a disability pension for the rest of his/her life this will result in a considerable amount of money.097 DKK per month.760.
The amount of savings is particularly dependent upon our ability to succeed in the following: N N N To avoid “expensive” waiting times To achieve the best possible communication between the involved health professionals and the relevant social authorities.The implementation of improved and more effective treatment courses will in addition to saving money in the health care system also reduce costs related to sick-leave beneﬁts and disability pensions. To avoid unnecessary and meaningless examinations and treatments 98 . H OW CAN THESE SAVINGS BE ACHIEVED It is important to underscore that the desired treatment course can enhance the likelihood of achieving satisfactory treatment results thus decreasing the likelihood of chronic symptom development in addition to considerable savings.
the implementation of inter-disciplinary reference programs and guidelines and improved professional co-operation and communication are all essential. which far surpasses previous rates. there have been over 5 million contacts with patients in the primary and secondary health care sectors due to low-back pain. For example. 1 & 2”. health professionals and decision makers in the health care system have participated in intense professional and organisational discussions based upon our initial recommendations. 1” Since the publication of our ﬁrst volume. Volumes 1 and 2”was held in Copenhagen on the ﬁrst of August 1995. Vol. if we are to optimise our efforts in the assessment and treatment of low back pain patients. Only if we are at the forefront of international developments will we be able to offer optimal treatments at the local level. New knowledge in research reports and evidence based clinical “guidelines” are also being published at a pace. The awareness of this issue was already great during our work on “Low-back Pain. 99 . Since that time. It is therefore important to conclude with the same message that we presented in Low-back Pain Volume 1. That a massive effort involving increased research. Many new initiatives have already taken place.9 Concluding Comments The ﬁrst meeting of our Low-back pain group that produced “Lowback Pain. In all likelihood this should be carried out within 3-4 years. Our work group is very aware of the size of the low-back pain problem and it has been very gratifying to note that we have discerned a willingness to tackle the problem seriously at all decision making levels of the health care system. Some patients have experienced severely disabling symptoms while others have experienced a lesser degree of trouble. It is already time to consider when we should begin planning the updating of “Low-back Pain Vol. in over 7 counties (as of June 1998) there have been inter-disciplinary meetings. which have dealt with the possibilities of implementing our recommendations at the local level. post-graduate education. Professional developments in the international forum regarding the “back problem” are being carried out at a rapid pace.
Århus County. The fee schedule for physiothera pists. The costs include treatment as well as individual exercise therapy. The cost of a consultation is 96 DKK and this covers a consultation during opening hours from Monday to Friday from 8 a. General Practitioner The fee schedule for consulting a general practitioner was provided by the National Public Health Insurance. A consultation is made up from 1-6 modules per session and the duration of a consultation will therefore last from 15-90 minutes.m.APPENDIX Examples of costs associated with the treatment of “low-back pain” T REATMENTS IN THE PRIMARY HEALTH CARE SECTOR Examples of the costs associated with the assessment and treatment of low-back pain patients in the primary health care sector are shown in Table 1.m. The fees for relaxation therapists and medication costs are based upon evaluations by the expert panel. The fee schedule for consulting a general practitioner was provided by the National Public Health Insurance. chiropractors and medical specialists were provided by the National Public Health Insurance Department of Negotiations and are given as 1997 ﬁgures. to 4 p. During the period of treatment in our hypothetical model we assumed that a patient would consult his general practitioner 4 times. 1997. Århus County. 1997. The calculations begin with a hypothetical treatment course lasting for a period of 4 weeks.m. Consultation costs are derived according to a module system in which every module is deﬁned as an independent service and is estimated to take approximately 15 minutes. A module is compensated by the same amount regardless of its content. to 4 p. The fees are for a consultation from Monday to Friday from 8 a. During the period of treatment in our hypothetical 4-week treatment model we assumed that a patient would consult a physiotherapist a minimum 100 . Practising Physiotherapist The fee schedule for consulting a physiotherapist (1997 ﬁgures) has been provided by the National Public Health Insurance Department of Negotiations.m.
The given fees are those agreed upon by the National Public Health Insurance Department of Negotiations and the Association of Medical Specialists for patients with ordinary public health insurance. Costs related to the expensive medication during the 4-week period will therefore amount to 196. 1) chiropractic examination and treatment. 101 . This results in a total cost of 56. if pills are purchased in bottles of 100 pills. Medical Specialist During the period of treatment in our hypothetical 4-week treatment model we assumed that a patient would consult a medical specialist 3 times. Costs according to 1996 prices are 1. Medication Costs We assume that medication treatment will last for a minimum of 4 weeks.8% as well as holiday pay. The price per day will be 6.of 8 times averaging 3 modules per visit.00 DKK for 30 days. Relaxation Therapist During the period of treatment in our hypothetical 4-week treatment model we assumed that a patient would consult a relaxation therapist once a week. 2) chiropractic treatment. During the course of treatment approximately 200 tablets will be taken. Consultation fees include extra services involved in treatment such as injections and so forth. Our calculations begin with an inexpensive pain relieving medicine in full dose as well as an expensive arthritic medication. The cost of each module is 60 DKK Practising Chiropractor The fee schedule for consulting a chiropractor (1997 ﬁgures) has been provided by the National Public Health Insurance Department of Negotiations. The fee has been set at 300 DKK per visit.00 DKK. 3) supplementary services and 4) x-ray examination. During the period of treatment in our hypothetical 4-week treatment model we assumed that a patient would consult a chiropractor 7 times. The fees include a supplement of 12.85 DKK per day. The inexpensive medication is paracetamol which we assume will be taken in a daily doses of 4 grams. Consultations are divided into. The expensive medicine chosen was tiaprofensyre where the daily doses has been set at 2 times 300 mg.5 DKK if pills are purchased in bottles of 100 pills (1996 prices).
X-ray examination of the spine. “Production. in private practice Medical specialist: 1 1 1 1 1 1 Initial consultation Additional services Second consultation Additional services Third consultation Additional services In total.and effectiveness measurements in the hospital sector.200 434 50 217 50 106 50 434 50 217 50 106 50 907 295 147 74 295 882 148 1.CT-scan . TABLE 1 Costs associated with 4 weeks of treatment for low-back patients in the primary health care sector Number 4 8 1 6 2 Type of service General practitioner: Consultations Physiotherapist in private practice: Treatments Chiropractor in private practice: Chiropractic basic examination and treatment Chiropractic service Supplementary services In total 7.X-ray examination of the spine.000 377 1.Diagnostic Imaging Table 1 also includes costs associated with different types of diagnostic imaging which would be relevant in conjunction with the treatment of back patients.cost models used in practice”.440 1.000 1. 3 consultations at a medical specialist Relaxation therapist: 4 1 1 1 4 1 1 Treatments Medication: .chiropractor .000 56 196 56 196 300 1. visits at a chiro. Costs given for imaging examinations are based upon previously undertaken calculations1 as well as calculations carried out at the Hillerød Hospital (MR-scans).hospital .440 1) Anni-Ankjær-Jensen.000 1.325 DKK 96 180 In total 384 1. 102 . X-ray examination of the lumbar spine will usually involve 4 projections. Cost calculations for the department of radiology in the DSI-report 94-04.Inexpensive medication .Expensive medication Diagnostic imaging: .MR-scan 360 1.
One is left with the indirect costs such as wages during breaks and waiting time. water. Due to the fact that the total direct costs of the department cannot be exactly determined. We have therefore added a cost to all treatments of 32%. cleaning. heat. daily operational expenses. Conservative treatment while hospitalised for 2 weeks or treatment at a spine center Table 2 includes examples of two alternative treatments in the hospital sector for patients suffering from low-back pain. A more detailed description of this method of calculation is provided in appendix C. This method only addresses the costs. All calculations are excluding interest and depreciation costs. costs related to educational activities and new major purchases. The “bottom-up” principle involves adding all of the direct costs that are related to a given activity/treatment.T REATMENT IN THE HOSPITAL SECTOR The following examples of costs associated with hospital treatment are based upon ﬁgures from a particular hospital. etc. 1) conservative care while hospitalised for 2 weeks and 2) ambulatory treatment in a spine centre. This principle is used to calculate costs associated with ambulatory treatment in spine centers and for cost calculations associated with disc herniation operations including costs related to anaesthesia. The ﬁrst alternative includes the cost for using a hospi- 103 . which we have called “overhead”. electricity and so forth represent approximately 32% of the costs associated with running the departments in which patients are treated. Method We have used to different methods for our calculations. which can be directly related to the given activity. etc. This principle is used for calculations related to costs per day for hospitalised patients. If it is desired one can add an amount which represents a part of the indirect costs associated with the department.) and indirect costs (utilisation of administration. The hospital’s costs associated with administration. materials. The “topdown” principle involves a division of the total costs by the total activity in the department in question during the period in question. Calculations use total average costs because costs involve both direct costs (such as physician and nurse times. heat. 30% is the number usually used. repairs.).
We assume that treatment at a spine centre involves 4 ambulatory consultations (30 minutes each) as well as one telephone contact in conjunction with each consultation. 4 telephone conversations of < 20 min. nurse. TABLE 2 Costs associated with 2 weeks of conservative treatment at a hospital and ambulatory treatment at a spine center Alternative I (hospitalisation) Number 14 4 Cost category Days of hospitalisation X-rays of the spine Samlet alternativ I DKK 1.tal bed2 in the department where the patient is hospitalised.440 24. The costs associated with the latter alternative include wages to the personnel that are involved with the ambulatory care (physician.440 3.127 alternative II (ambulatory care) Salaries 4 ambulatory treatments of < 30 min. We assume that during the period of hospitalisation a plain x-ray as well as a CT scan will be undertaken. 120 120 120 120 DKK 376 154 180 148 100 80 Cost category X-rays of the spine In total. In addition. there are costs associated with resources provided by other hospital departments.duration physician time Number 4 2) We refer to appendix B for a more detailed review of the method used to calculate the costs associated with the utilisation of a hospital bed.806 1. 104 .duration 1 physician 1 nurse 1 physiotherapist 1 secretary Other costs such as materials etc.757 1. secretary and so forth).246 Min. physiotherapist. alternative II +30% indirect costs associated with using the department 376 DKK 360 In total 752 308 360 296 100 501 In total 1.629 360 In total 22. In addition to material costs there are the costs associated with x-ray and CT scans.
The ﬁrst alternative is treatment at a “back school”.680 2.964 DKK 1.000 DKK In total 105 . which takes place at a hospital. 3) the operation and anesthesia. 4) hospitalisation.764 888 148 2. The resource utilisation can be divided into 4 phases: 1) pre-hospitalisation examination.800 60 1. The second TABLE 4 Costs associated with post-operative rehabilitation Cost category Alternative l:(treatment at a back school) Total cost for alternative I: Alternative II:(treatment at a physiotherapy clinic) 24 training sessions – 28 modules: Alternative III:(treatment at a chiropractic clinic) 12 basic clinical services: 12 training sessions 2 supplementary services Total costs of alternative III: 147 74 74 1. 2) a consultation with an anesthesiologist.775 11.403 17. Appendix A includes a more detailed review of the calculations associated with each of these 4 areas.000 2.580 269 COSTS ASSOCIATED WITH REHABILITATION Table 4 shows 3 alternative methods of rehabilitation a spine. TABLE 3 Costs associated with a disc herniation operation Cost category Pre-operative examination/CT-scan Anesthesia consultation Operation: Operation department Anesthesia department 7 days of hospitalisation Total direct costs 2.937 1. The cost was estimated by an expert panel.Operation for disc herniation Table 3 illustrates a calculation of the costs associated with hospitalisation and operation for a disc herniation.
65 DKK per hour. Sick-leave beneﬁts are calculated by multiplying the number of hours by the hourly wage. 12 training sessions and 2 supplemental basic services.. the maximum sick-leave beneﬁt that a patient can receive per week is given.688 In total 5. Box 2020 DK-1012 Copenhagen Denmark COSTS ASSOCIATED WITH SICK . The maximum hourly wage cannot exceed the maximal total sick-leave beneﬁt divided by the number of weekly hours that have been agreed upon by the Danish Employers Association and the Labour Unions. These appendices (in danish only) can be retrieved by contacting: Danish Institute for Health Technology Assessment National Board of Health 13 Amaliegade P.alternative takes place at a physiotherapy clinic. The hourly wage includes the basic wage plus eventual additional moneys paid for working at odd hours as well as other personal supplements. The last alternative takes place at a chiropractic clinic. weekend and holiday pay.LEAVE BENEFITS In Table 5. It is necessary to know the numbers of hours as well as the hourly wage during sick leave in order to calculate beneﬁts. Not included are holiday beneﬁts. In practical terms. pension and social security contributions.O. one would receive full pay during sick-leave if one’s hourly wage is less that 72. TABLE 5 Sick-leave beneﬁts for 2 weeks Number of weeks 2 Source: Social services 1998: Insurance information. The beneﬁts are based upon the person’s income and are calculated according to the hourly wage that the wage earner would receive during sick leave minus the amount that would be paid to the work-market contribution fund. Copenhagen Sick-leave beneﬁts per week 2.376 106 . during which the patient receives 28 modules of rehabilitation. The patient will receive 12 basic services.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.