Back pain: a National Health Priority Area in Australia?

Given that up to 80% of Australians experience back pain and 10% have significant disability as a result, should back pain be classified as a National Health Priority Area (NHPA) and integrated into a National Service Improvement Framework area?

The Australian Government established the NHPA initiative in 1996, aiming to engage cooperation between government and non-government organisations to monitor, report on and develop strategies to improve health outcomes for Australians.1 The initiative seeks to focus public attention and health policy on areas of health which impose a significant national burden, but also where improved health outcomes are attainable to reduce that burden2 (Box 1). There are currently seven NHPAs (Box 2). In addition to NHPAs, a strategic national policy approach to manage and improve chronic disease prevention and care was endorsed by the Australian Health Ministers in 2005. This approach includes a National Chronic Disease Strategy, five National Service Improvement Frameworks (for asthma; cancer; diabetes; heart, stroke and vascular disease; and osteoarthritis, rheumatoid arthritis and osteoporosis), and a blueprint for nation-wide surveillance of chronic diseases and associated determinants.4

The current federal government has provided strong indications that the NHPA initiative will be retained for chronic diseases and expanded to focus on modifiable risk factors for chronic disease and illness, notably obesity.5 While welcome, classifying obesity as an NHPA is a departure from the original chronic disease-specific selection criteria of the NHPAs, and raises the issue of whether other conditions, such as back pain, should also be included within the NHPA and National Service Improvement Frameworks.

An investigation of the burden of all diseases in Australia in 2003 found back pain to be among the top 20 burden-imposing diseases in terms of disability-adjusted life-years.6 Lifetime prevalence of low back pain is reported to be as high as 79.2% in Australian adults7 and 84% in adolescents,8 with about one in 10 people experiencing significant activity limitation.7 Back pain and intervertebral disc disorders were identified as by far the most significant work-related problems in the National Health Survey for the financial year 2004–05,9 and were reported as a long-term health condition more frequently than NHPA conditions such as asthma, osteoarthritis and hypertension.6,10 In addition, the prevalence of back pain has increased over successive national surveys to a greater extent than some current NHPA conditions (Box 3), and this may have major implications for Australian productivity.

In 2006, the Council of Australian Governments announced the National Reform Agenda (NRA) to address the challenges facing Australia’s economy and drive national prosperity.11 Human capital, a key element of the NRA, is dependent on increasing workforce participation, retention, motivation and productivity by optimising health and minimising disability. Back pain is associated with significant workforce absenteeism and “presenteeism” (being at work, but unproductive), thus imposing a significant threat to Australia’s human capital.

Although back pain imposes the greatest burden during middle-age, important from a societal work productivity perspective, it is not trivial in youth or old age. While the prevalence of back pain is reportedly low in children (1%–6%), it rises sharply during adolescence (18%–50%) to approach the prevalence in adults.12,13 In Australia, back pain is one of the most common long-term health conditions reported by teenagers and young adults (9.1% for 15–24-year-olds and 15.3% for 25–34-year-olds).6 Back pain experienced by children and adolescents is associated with disability in up to 94% of cases,14 and of imminent concern is the increasing prevalence of back pain in adolescents, suggesting a growing burden into adulthood15 accompanied by a threat to future workforce productivity. At the other end of the age spectrum, it is commonly believed that the prevalence of back pain decreases around the middle of the sixth decade, but recent epidemiological evidence suggests that this may only be true for benign back pain, and that severe back pain increases into old age.16,17 Taken together, these data highlight the magnitude of the problem and provide substantive evidence for considering making back pain an NHPA.

NHPAs are relevant for health consumers and their families, health providers and policymakers. They provide a focus for policy directives and decisions, basic and clinical research priorities, education, and community awareness, and participation in health promotion and prevention of chronic disease. The value of NHPAs, and health policies generally, may be seen through the implementation of change in practice, service, and governance policies.18 For example, reductions in tobacco smoking, an increased proportion of adults performing physical activity, and an uptake of health screening programs including mammography and Pap smear testing2 reflect positive changes in public awareness and government support for reducing the risks of developing some NHPA conditions. Moreover, in response to the NRA, several reforms and programs have also been proposed for diabetes and mental health.19

Back pain meets the broad criteria for a NHPA (Box 1) and shares risk factors common to other NHPA conditions (Box 4); it imposes a significant personal and societal burden in Australia, and, importantly, health outcomes can be improved by adopting a biopsychosocial approach to its management.19 While the vast majority of acute presentations are considered to be caused by mechanical non-specific factors, there is strong evidence that staying active and continuing usual activities leads to a faster recovery and a lower risk of chronic pain and disability.20 Nonetheless, recent evidence suggests that nearly a third of individuals do not achieve a full recovery and return to work 12 months after the initial onset of pain,21 and in the workplace, back pain is an enormous contributor to lost productivity, second only to mental health.

Like obesity, back pain differs in some respects to other NHPA conditions. Back pain is neither a single chronic disease with a definitive aetiology nor an injury, and it does not cause death. Furthermore, disability due to back pain may be more amenable to prevention, and significant health and financial benefits could be observed quite quickly by improving the application of evidence-based practice. For example, population strategies such as mass media campaigns that aim to demedicalise the problem have been shown to be effective in shifting back pain-related beliefs of both society and doctors and to result in improved health and financial outcomes.22 Nevertheless, implementation of evidence in this area presents a major challenge, not least because of the many stakeholders involved. Back pain-related disability involves not only the health care field, but also workplace, compensation, and societal issues.23

The advantages and disadvantages of integrating back pain into the NHPA framework are summarised in Box 5. On the merit side, it may provide opportunities for preventing or minimising disability, improve the dissemination and uptake of best-practice back pain management guidelines in primary care,20 provide a more cohesive focus for considering changes to health policy and legislation (eg, recent changes to legislation about whiplash in Australia have improved outcomes for neck-related disability24) and provide a way to consider the views of the wide range of stakeholders. On the other hand, making back pain an NHPA has the potential to paradoxically increase the burden of back pain by inadvertently increasing the focus on the problem itself and providing justification for those with (or without) vested interests to promote clinically ineffective interventions. This is of some concern as we have recently observed that a self-reported special interest in back pain among Australian general practitioners is strongly associated with back pain management beliefs and practices that are contrary to the best available evidence.25 This may be analogous to the workplace epidemic of repetitive strain injuries seen in Australia in the 1980s, believed to have arisen as a result of excessive medicalisation of the phenomenon coincident with other industrial, political and social factors.26

While back pain could become a new NHPA, there is also merit in integrating back pain into the musculoskeletal conditions NHPA (Box 2). Strategies to reduce the burden of these conditions overlap and may be equally applicable to back pain.

The NHPA framework aims to limit the development and progression of chronic conditions, slow the onset of complications that cause disability, reduce preventable hospital admissions, and reduce geographical and other variations in care — all of these aims are highly relevant to back pain. As back pain becomes an increasingly significant public health problem, it is time to carefully consider the merits of making back pain a national health priority. A first step would be informed decision making by health policymakers through consultation with clinicians, researchers, non-government organisations and professional groups, with due consideration of the potential risks.