Vast numbers of people with lower back pain across the world are being harmed, not helped, by the surgery, injections and dangerous opioid drugs they are given, according to a major new report.

More than 540 million people suffer low back pain, the commonest cause of disability in the world. But their condition is often being made worse by costly high-tech interventions and bed rest in what could amount to medical negligence on a global scale.

What these people really need to get better is exercise and the earliest possible return to work and their normal life, experts say.



In some countries, treating unexplained back pain is a lucrative business for doctors and hospitals, and the three papers in the Lancet medical journal, released on Wednesday, call on governments and health leaders to act together to “tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo”.

Back pain is a huge burden on individuals, health services and economies. Every year, a total of 1m years of productive life are lost in the UK because of disability from low back pain, 3m in the USA and 300,000 in Australia, say the papers.

Most people suffer an episode of low back pain at some point in middle age, said Prof Martin Underwood from Warwick University’s medical school, one of the authors. “In the vast majority of cases we don’t know what the cause is,” he said. Only 1% are linked to serious disease such as an infection or cancer.

“There has to be a cause,” he said. “There is an injury – using the word in the medical sense –of some sort that sets it off.” But it is rare that doctors can establish what that is. Psychological, social and economic factors can all play a part. Many people have other pain as well and there are lifestyle links, such as obesity, smoking and lack of activity. Most episodes don’t last long, but one in three people will have a recurrence within a year.

Investigating using MRI scans is counterproductive, the experts say. MRIs will pick up physical abnormalities that may not be the source of the pain. Scans often result in surgery or other interventions, but the evidence shows that fusing the discs in the spine, inserting artificial discs or giving spinal injections does not usually help. Nor does bed rest and staying off work.

In the UK, the NHS has guidance for doctors on non-specific lower back pain that promotes physical exercise and recommends against surgery. But in the United States, operations are very common, setting an example to the rest of the world. “The really big worry is that we have got a lot of really high-tech treatments, a lot of which are not of proven benefit,” said Underwood. “In the low- and middle-income countries, the middle classes are going to start to access and use them.”

Prof Nadine Foster from Keele University, one of the series authors, said there was no question of denying the reality of the problem. “The papers are drawing attention to the rising levels of disability associated with back pain,” she said. The authors wanted to highlight better solutions than high-tech interventions.

The NHS was doing better than the USA: “We are seeing fewer patients offered fusion surgery,” she said, “but we are still seeing many patients offered injections that are of questionable value. They are very expensive for the NHS and not very helpful for patients.”

There is also concern about the rising number of opioid painkiller prescriptions in the NHS. “Recent trials have shown they are not more effective than other much safer drugs, yet many patients are still being put on drugs that have opioids in them,” Foster said. People should be given “the safest possible drugs for the shortest possible time at the lowest possible dose”.

Prescriptions for back pain in the USA have fuelled the opioid crisis there. “The epidemic of addiction and rising mortality resulting from increased opioid prescribing in the USA over the past 20 years is a dramatic example of the disastrous effects of damaging medical intervention,” write the Lancet series authors.

The public needs to be protected from “unproven or harmful approaches”, say the experts. Some countries are acting: Australia and the Netherlands are looking at ceasing to pay for some invasive treatments. The experts call for health professionals and patients to adopt what they call a “positive health” approach, defined as “the ability to adapt and to self-manage, in the face of social, physical, and emotional challenges”.

That involves changing beliefs about back pain, so that doctors help patients to live “meaningful, high-quality lives” while people become less likely to expect a diagnosis or a cure.

Prof Helen Stokes-Lampard, chair of the Royal College of GPs, said: “It’s clear from this study that much more needs to be done worldwide, to dispel myths around the best ways to treat back pain – rest, for example, is one of the worst approaches, yet this advice is commonplace in many countries.

“This is a really interesting and important study that should give healthcare professionals across the world a lot of food for thought, but also poses helpful challenge to those producing clinical guidelines – and it’s important that the findings are taken seriously and into consideration as guidelines are developed and updated.”