Dear Editor,
Low back pain (LBP) is the leading cause of disability and an economic burden worldwide. Only a few percent of patients could find a certain physical pathology, such as infection, tumor invasion, or vertebral fracture. The interaction of physical, psychological, and social stimuli can best explain LBP (1). Studies have shown that two triggers lead to an unexpected increase in the incidence of back pain in the community: natural disasters and economic decline (2, 3). There is strong evidence that poor socioeconomic status (SES) is associated with LBP, its chronicity, and accompanying disability (4). Among the economic variables, the unemployment rate is significantly related to the incidence of back pain (5).
The statistics of the International Monetary Fund on Iran's economy show an almost zero percent growth rate in the last decade and predict lower economic growth in 2023. Global growth will slow down, and the unemployment rate will predictably increase (6). These data, with accompanying emotional stress caused by job insecurity, predispose society to the burden of SES-related health problems, namely LBP. We, clinicians, must play our part in managing this public health problem and economic burden.
Health care utilization and related costs and disability due to low back pain vary substantially between countries and are influenced by social systems and local culture as well as beliefs about cause and effect. There are wrong beliefs contrary to the scientific evidence in clinicians and patients. In addition, the worry of being sued by patients leads to unnecessary diagnostic and therapeutic measures. For instance, limited evidence supports the clinical utility of radiologic or electrodiagnostic studies in acute or subacute LBP or the long-term benefit of medication or steroid injection for nonspecific low back pain. Most patients have a misconception about the benefits of extended rest for back pain. Correcting these misbehaviors and replacing them with evidence-based treatment strategies is even more important in low-income countries, where the health system is often fragile and not equipped to cope with this growing burden.
Cochrane systematic reviews suggest that after excluding red flag signs and symptoms, it would be reasonable to prescribe more feasible therapeutic modalities such as exercise therapy, including core strengthening (7), acupuncture treatment (8), and early return to work with necessary workplace modifications (9). An early assessment is useful for barriers to recovery, such as fear-avoidance beliefs and psychosocial factors (10). To establish this practice, health policymakers should develop a national guideline with the help of a multidisciplinary team of experts. Physicians should receive more legal protection against complaints contrary to clinical guidelines, and finally, more work needs to be done on people's beliefs about back pain in the reference media. These measures do not reduce the government's responsibility to create economic prosperity and employment. Clinicians warn about the outlook and perform their daily practices as best as possible within the existing structure.
