The burden of back pain : evaluation of costs and health outcomes

Abstract: Background: Back pain is a leading cause of disability in the world. Beyond the negative impact on people’s health and quality of life, back pain is associated with substantial costs both within and outside the health care sector. While there are many alternative strategies for the treatment and management of back pain, there is a lack of knowledge about their effectiveness, costs and cost-effectiveness. Such information could guide decision-makers regarding which treatment strategies to use for back pain. The aim of the thesis was to explore the costs of back pain, and to explore the effectiveness, costs and cost-effectiveness of different treatments for low back pain. Methods: Studies I and II used a clinical trial design, where data from multiple study centres were combined and analysed in order to increase understanding of changes in patient-reported outcome and costs over time. Study III was a systematic mapping of systematic reviews on the effectiveness of various primary care treatments for chronic low back pain (CLBP). Study IV was a register study where data from multiple national registers were combined and productivity losses for patients with back pain were analysed. Results: There were significant productivity losses due to long-term sickness absence and disability pension among individuals of working age who had undergone a first specialist health care visit for back pain. Productivity losses may be affected by sociodemographic factors and it was indicated that individuals with back pain with an additional diagnosis might have higher productivity losses than individuals with only a back pain diagnosis. There was evidence that some primary care treatments (non-steroidal anti-inflammatory drugs, opioids, spinal manipulation, multidisciplinary biopsychosocial rehabilitation, and therapeutic ultrasound) had positive effects on pain and/or function in patients with CLBP. However, there are considerable knowledge gaps for most treatments. There were statistically significant improvements in health outcomes (back pain-related functional limitation, pain intensity, and health-related quality of life) from a 4-week treatment with chiropractic care for patients with non-specific acute or chronic back pain. There were no statistically significant differences in back pain-related functional limitation, pain intensity, health-related quality of life, costs or quality-adjusted life years when physiotherapy, chiropractic care, and the combination of physiotherapy and chiropractic care were compared with advice among patients with non-specific CLBP over a 6-month period. Conclusion: Back pain is associated with large productivity losses for individuals in the working age. Individuals with a first specialist health care visit for back pain have considerable greater productivity losses than those without back pain. Women tend to have higher productivity losses than men, and individuals with at least one other diagnosis tend to have higher productivity losses compared to those with only a back-pain diagnosis. Chiropractic care of patients with acute or chronic back pain may, over a 1-month period, improve health outcomes (back pain-related functional limitation, pain intensity, and health-related quality of life). There were no statistically significant differences when physiotherapy, chiropractic care, and combination treatment were compared with advice, over a 6-month period, in the treatment of patients with CLBP in Sweden. Due to a high dropout rate and low power, these results should be interpreted with caution, and differences between the treatment groups cannot be ruled out. Some primary care treatments had positive effects on pain and/or function for patients with CLBP. However, these effects were usually not clinically important, and there are considerable knowledge gaps for most back pain treatments. In conclusion, there is a great need for high-quality, large-scale studies to further study the effectiveness, costs and cost-effectiveness of primary care treatments for CLBP.