Back pain is a common and costly health problem. It is the leading cause of disability worldwide and a "call to action" recently published in The Lancet highlights the risks of over-medicalisation of back pain globally.
In our recent research study, published in BMC Health Services Research, we found that many individuals suffering chronic back pain are not able to access non-physician options like physiotherapy.
We compared self-reported use of family physician, chiropractor and physiotherapy services among 25,545 Canadian adults with chronic back pain and found lower use of services among certain groups.
For example, people with lower income and education levels were less likely to seek care with physiotherapists in comparison to family physicians. As were rural and remote residents.
This lack of access is especially unfortunate, as the evidence shows chronic back pain to be more common among people with lower incomes and those who live in rural or remote areas.
Over medicalisation of back pain
Back pain is among the most common reasons for seeing a family doctor in many countries. Universal health-care coverage of back pain is usually limited to prescription medications, diagnostic imaging or onward referral to publicly funded medical specialists.
This leads to an over-medicalisation of back pain, involving excessive medical investigations using X-rays, CT scans and MRIs and low-value health-care approaches—such as long-term use of opioids. All of these increase health-care costs and the risk of long-term back-related disability.
Many cases of back pain are in fact best managed through education, exercise and manual treatment, or a combination of services in addition to those provided by a family doctor.
In Canada, one in five adults experience chronic back pain and the health-care costs of this are estimated at between $6 and $12 billion annually. An estimated one third of Canadians do not have the additional health insurance that would help to cover the costs of non-physician care options like private physiotherapy services.
Ironically, having private health insurance for health costs not covered by the public system is highly associated with income.
Physiotherapy can curb opioid use
Improving access to affordable health care for those who need it was among the several recommendations arising from The Lancet low back pain series working group.
Improving access to non-drug back pain treatment options like physiotherapy is an especially important public health issue in Canada in light of the current opioid crisis.
More than half of opioid users report having back pain. Treatment by physiotherapists for back pain can help curb the use of pain medications like opioids.
The first and last recommendations of the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain include referral to multidisciplinary non-physician care providers.
Unfortunately, the barriers to access for non-physician services outside of what is publicly funded make these guidelines challenging to implement.
Telehealth and robots can help
Improving access to physiotherapy and other potentially beneficial services for people with chronic back pain requires rethinking the way typical back care is delivered in Canada.
Advocating for insurers and health policy-makers to enhance funding these services would be a good start.
Models of care that include physiotherapists within publicly funded health-care teams have shown benefit.
Ongoing research in Canada is investigating the feasibility and impact of models that embed physiotherapists within family physician's practices.
Using telehealth and other technology like remote presence robots is another way that rural and remote access barriers to back pain care might be overcome.
The gaps in access to care highlighted by our research show that access to physiotherapy care is not equitable among Canadians with chronic back pain. New and innovative approaches are needed to address these access challenges.
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