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Disability from low back pain is a growing public health problem in
Australia and developed countries worldwide, and one of the major
issues targeted in the Bone and Joint Decade (2000-2010).1 Most
population-based surveys of back pain report a point prevalence of
15%-30%, a one-year prevalence of 50%, and a lifetime prevalence of
60%-80%.2 Although episodes of acute low back pain are
mostly short-lived, back complaints still constitute the second
most common symptom (after upper respiratory complaints) prompting
general practice encounters.3 Furthermore, disability
from back pain places a significant socioeconomic burden on the
individual and the community. In Australia, back problems are the
leading specific musculoskeletal cause of health system
expenditure, with an estimated total cost of $700 million in
1993-1994.4 Moreover, these costs are
rising: in Victoria alone, claims lodged for back injury with the
workers' compensation scheme cost the community $510 million in the
1999-2000 financial year.5
Attempts to reduce the burden of disability associated with back pain
have often been directed towards prevention of pain per se,
particularly in an occupational setting. Although direct
involvement of workplace management in primary prevention
strategies has had positive effects, interventions such as
education, training and exercise programs for the back, ergonomic
interventions and screening potential employees for risk factors
for the development of back pain or injury have had limited
success.6 Paradoxically,
interventions aimed at preventing chronicity, such as early
exercise, physiotherapy, rehabilitation and education programs,
when implemented early (ie, within the first few weeks of back pain),
are largely ineffective for improving longer-term
outcomes.7
Attitudes and beliefs, particularly fear-avoidance beliefs,
pain-coping strategies and illness behaviours, are important
issues to consider when treating patients with back pain.8 While
psychosocial approaches that seek to remedy unfounded fears and poor
coping methods have met with limited success in treating patients
with established chronic back disability, these approaches may be
effective when implemented early in the course of back pain and could
even be of value when directed towards those who have yet to develop
back complaints. Provision of positive messages, such as those
designed to improve attitudes to back pain and diminish fear, reduce
self-reported disability in patients presenting with low back pain
in general practice.9 These interventions also
reduce extended work absence in industrial settings.10,11
The Victorian WorkCover Authority's statewide media campaign "Back
pain — don't take it lying down", which commenced in 1997 (Box 1),
aimed to provide a new approach through prime-time television
advertisements featuring health professionals, and sports and
local television celebrities. The messages, all endorsed by the
relevant professional healthcare organisations, were
simple:
- back pain is not a serious medical problem;
- disability can be reduced and even prevented by positive attitudes;
and
- treatment should consist of continuing to perform usual
activities, not resting for prolonged periods, exercising and
remaining at work.
The campaign counselled individuals with low back pain, their
doctors and employers to avoid excessive medicalisation of the
problem, and unnecessary diagnostic testing and treatment.
A three-part evaluation of this campaign (evaluating general
population attitudes, general practitioners, and the WorkCover
Authority claims database) suggests that there has been widespread
adoption of these messages (Box 2).13,14 The campaign
successfully managed to:
- "de-medicalise" a public health problem;
- ease the burden on general practitioners and specialists;
- empower workers to solve their own health challenges; and
- save workers' compensation payments.
The success of the campaign has been attributed to many factors,
including the simple, direct language used to convey the messages,
and the evidence-based content, both pioneered by the authors of
The back book.12 In addition, virtually
every professional body with a stake in back pain in Australia
supported the campaign.
Before this campaign, there was limited empirical evidence that
primary preventive interventions reduce the overall burden of
illness associated with low back pain. Now, evaluation of the
campaign has shown that a public policy initiative directed towards
managing the disability of back pain can be highly successful. There
are compelling arguments for this approach. These include, firstly,
the impression that informative interventions may be of more value
when initiated early, even before the onset of symptoms; and,
secondly, predictive models of low back pain are not presently able to
identify those at risk of disability. By targeting the entire
population, this public health approach reaches those
hard-to-identify high-risk groups. There is evidence that a
population strategy of universal change has greater overall effect
than targeted high-risk strategies. Finally, the population
approach may be an effective way of modifying doctors' behaviour,
both through direct influences as well as through a change in the
attitudes of their patients.
Media campaigns are an established strategy for delivering
preventive health messages. They have been particularly successful
in Australia in altering health-related behaviours, such as
sunlight exposure through the Slip! Slop! Slap program and
smoking through the Quit program. With good evidence that
negative attitudes and beliefs are important predictors of
disability related to back pain, altering societal views of back pain
would seem a highly appropriate policy to adopt.
The long-term impact of this campaign is not clear. Recent publicity
by the Victorian WorkCover Authority has focused on ergonomic
interventions in the workplace — strategies that the United States
has controversially rejected. Clinical effectiveness is not the
only influence on policy:15 policymakers' own
interests and ideologies are often significant. We may have to look to
other interested industrialised societies, such as Sweden, the
Netherlands or Canada, for evidence of this novel campaign's
long-term effectiveness.
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