BACK DISORDERS
Back ailments, technically called "mechanical
pathologies of the spine" are defined as those disorders
in which the pain varies according to posture, movement and
exertion, and is not due to systemic illnesses such as cancer
or infections. They include such diagnoses as vertebral arthrosis,
disc herniation, disc protrusion, muscle contraction, scoliosis,
spondylolisthesis, spinal stenosis or back pains of an unknown
cause.
They are the most common complaint in industrialized
countries.80% of the population suffers them at one
time or another in their lives, and they are the primary cause
of work absenteeism. It is estimated that the expense they
generate represents approximately 2% of the Gross Domestic
Product. In addition, the available data shows that every
year their frequency increases along with the costs they generate.
For these reasons, they are the ailments with the greatest
social impact in industrialized countries today and therefore,
constitute the priority field of research for the Foundation,
which is interested in all aspects related to them.
Causes and risk factors
In the first place, many of the causes
for back pain are not known. Various studies show that
most of the factors formerly blamed for back pain do not really
provoke it, while certain social or personal habits do in
fact influence the risk of suffering back pain. Thus, for
example, a scoliosis of less than 60º does not increase
the risk of suffering back pains, but practicing certain sports
on a competitive level does produce it among children. Hence,
the Kovacs Foundation makes scientific
studies studies to determine the frequency
of back pain in various segments of the population, along
with the habits,
factors and attitudes associated with a greater risk of
suffering pain.
Furthermore, among the general population
and even among doctors, it is commonly believed that postures
and certain elements from daily life, such as one's bed, have
a dramatic influence on the risk of back pain or on the evolution
of pain in those who suffer it. However, this relationship
has not been studied sufficiently with proper scientific methods,
so that there is no solid scientific base to determine which
characteristics are beneficial and which are harmful for back
health. The Foundation studies the
risk for the back that is associated with elements
of daily life.
The duration of the pain has as much as or
more impact on the quality of the patient's life than its
intensity, and most of the costs that back problems generate
to society come from chronic cases. For that reason, the Foundation
also studies those factors that increase the risk of the
pain becoming chronic, in order to make early identifications
of those patients in whom this risk is greater and in whom
it is justified to use measures, which due to their complexity
or cost, would be impossible to apply to all cases.
Assessment
The Foundation studies the essential aspects
on which the physician should focus his or her attention in
order to assess the patient's state and to determine the most
appropriate treatment for each specific case. That includes
identifying the possible causes and history, as well as the
signs that indicate the usefulness of diagnostic tests, keeping
in mind such considerations as their possible risks or side
effects, the time efficiency factor and the resources available.
Another problem is the lack of reliable, simple and practical
measuring instruments capable of determining, rapidly
and reliably, the degree of disorder caused by back problems.
Making these instruments available helps to determine how
aggressive a treatment it is justified to use, facilitates
the follow-up of the patients' evolution and allows an objective
assessment of their response to the treatments applied.
In this field, the Foundation develops instruments or
makes cross-cultural adaptations of those already existing
in other languages and settings, evaluating at the same time
their validity, reliability and measuring characteristics.
The results of this labor have, for example, allowed doctors
to improve their follow-up of the evolution of the degree
of limitation in daily activities caused by pain in order
to prescribe the most appropriate treatments at each moment
or to determine patients' mistaken beliefs about pain or their
fear and avoidance behaviors in order to identify those patients
in whom specific measures should be applied to correct these
beliefs or behaviors. Once these instruments have been developed
and validated, the Foundation makes them available, freely,
to the National Health System physicians so that they may
use them in attending patients in their daily clinical practice.
At the same time, the Foundation studies the influence
that each different aspect of back pain has on the patient's
quality of life and how that influence changes over time.
This allows strategies for treatment to be designed based
on those aspects that diminish the patient's quality of life.
Treatments
The treatments applied for back problems
include medical advice, pharmaceutical medication and a wide
variety of non-pharmaceutical treatments.
Very few of the recommendations doctors have traditionally
given patients with back pain have been evaluated scientifically.
And, when they have been, some have been shown to be useless
or even counterproductive, such as bed rest. The Foundation
promotes the evaluation of medical advice by means of methods
as rigorous as those applied to all other treatments.
Thus, for example, it has made the first double-blinded clinical
trial on the effect of the firmness of the mattress on back
pain, showing that it has a very important effect on the evolution
of the pain and that, as opposed to what is traditionally
recommended, a medium firm mattress improves patients' evolution
more than twice as much as a very firm mattress.
Law requires that the efficacy and safety
of medications be evaluated before they are put on
the market. However, the vast majority of corresponding studies
are sponsored by the pharmaceutical laboratories, which are
profit-making companies whose income depends on the results
of these studies. For that reason, the Foundation is open
to collaborating in these studies in order to ensure their
desired impartiality. Additionally, evidence on the effect
of certain medications on some patients who use them regularly
is lacking; also lacking are studies that determine beyond
the efficacy and safety of each medication individually, the
effectiveness and efficiency of different pharmacological
alternatives. For this reason, the Foundation is also open
to making the necessary studies to optimize the effectiveness
and efficiency of the pharmacological treatment used in patients
with back pain.
A field in which scientific evidence is especially
scarce is that of non-pharmaceutical treatments, such
as electrotherapy or surgery. Thus, the Foundation makes analyses
of the available scientific evidence on different non-pharmacological
treatments such as electrotherapy and different surgical techniques.
Its objective is to identify clearly those procedures which
have been shown to be effective and safe and to define the
cases in which their use is appropriate, in order to promote
their use in those cases in which they are indicated and under
the application conditions in which they have been shown to
be valid. The Foundation also sets out to identify those which
have been shown to have no positive effect, in order to recommend
the suppression of the useless expense of their application.
Additionally, the Foundation identifies those fields in which
there are no studies, and those in which studies are needed
urgently before continuing to expose the population to measures
of dubious efficacy and safety.
The main social, economic and health problem
are those patients with chronic pain without any indication
for surgery. It is calculated that the 20% most chronic patients
cause 80% of the costs generated by back ailments. Those patients
with the worst prognoses from the medical point of view are
those who suffer the greatest reduction in the quality of
their life and who generate the highest health care and labor
costs.
The Foundation develops treatments
for these cases and evaluates their efficiency and
effectiveness. Thus, in collaboration with the National Health
System, the Foundation has carried out and co-financed studies
on neuroreflexotherapy
(NRT) for the treatment of sub-acute and chronic back
ailments for which surgery is not indicated. First the efficacy
and the safety of this technology were demonstrated and the
results were repeated by a second, different, research team
in a different geographic and clinical setting. Afterwards,
its effect when applied under habitual care conditions was
evaluated (effectiveness) as well as the economic impact (efficiency)
that its use implied for the National Health System.
Thus it was shown that by adding this technology to the usual
treatment of those patients in the System in specific application
conditions, the patients' evolution improves between 3 and
8 times more, the costs are reduced by 75.3% and the efficiency
of the public resources spent on their treatment increases
between 6 and 22 times. Given these results, a pilot program
was established to use this technology in the System under
the conditions that had been evaluated to determine the degree
of satisfaction it produced among patients and doctors and
to collect the necessary information to make a rational planning
of its implantation (how to quantify its demand in care and
to determine the rate of its appropriate and inappropriate
use). Finally, it was incorporated into the System under the
conditions in which it had been shown to be effective, safe,
and efficient, and the necessary mechanisms were established
to evaluate on a consistent basis the outcome obtained through
its use.The process followed with this technology is, in the
Foundation's point of view, a good example of the system
which would be desirable to follow on a customary basis in
the implantation of new health technologies in the National
Health System, in order to ensure the efficacy, safety
and effectiveness of the treatments applied in it as well
as the efficiency of the public resources allotted to financing
it
Keeping in mind the enormous public expense
that back disorders generate for the Public Health System,
the Kovacs Foundation also studies the health and economic
impact entailed in the application of different treatments.
Thus, for example, it carries out community trials
to evaluate the effectiveness of different treatment protocols
in the management of patients with low back pain, both in
the National Health System as well as in the environment of
occupational accident and mutual insurance companies. These
studies assess the impact of the different treatment strategies
on the clinical evolution of patients and the costs they generate,
both from the point of view of health care and labor.
Clinical Practice
Very few of the treatments commonly used
for back ailments have been scientifically evaluated. Only
a small part of those evaluated have been done so correctly,
and of them, only a minority has been proven to be effective.
But, still more disturbing, the studies made suggest that
most primary care physicians are not aware of the scientific
evidence available when making their recommendations to patients.
In its evaluation, the Foundation studies the characteristics
of physicians' clinical practice in their treatment of
patients with back pain.
Furthermore, to improve the bases on which
doctors make their prescriptions, the Foundation participates
in the elaboration and implantation of clinical
guidelines, to be used by primary care physicians. These
guidelines provide in a practical fashion the standards for
diagnosis and treatment recommended by the available scientific
studies for each case.
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