There is evidence that Brazil, as like many other high-income countries, faces a significant challenge with overuse of medical services for LBP. High rates of consultation with medical specialists,29 imaging,25 and unnecessary surgeries16 are examples of such unwarranted practices. A high proportion of people with LBP seek medical specialists and emergency services rather than from general practitioners. A recent study showed that about 60% of Brazilian patients with chronic pain would seek orthopaedic surgeons (25%), pain specialists (14%), rheumatologists (12%) and neurologists (10%) as the entry point of healthcare.29 In contrast, only 8% of patients with chronic pain would first seek general practitioners.29 That phenomenon is particularly relevant in the private health sector and is potentially linked to the great number of unnecessary imaging and lumbar surgeries performed in Brazil.16

Lumbar surgeries considered unnecessary are those indicated as first line treatment for patients who might have benefited from non-invasive approaches. For people who had been correctly referred to surgery, the type of surgery performed is also an issue. For example, while clinical outcomes between decompression alone versus decompression with lumbar fusion in people with spinal stenosis are similar,30 fusion is associated with higher costs and increased hospitalization.30 Data from observational studies suggest that referring patients to multidisciplinary clinics31 and implementing second opinion programs32–34 can reduce rates of spinal surgery.35 Conditioning the recommendation for surgery to the opinion of a second, independent, physician has shown promising results as well. Data from the “Second Opinion Program”33,35 for spinal surgery in Brazil revealed that a second opinion reduced the number of lumbar surgeries by 50%. It also reduced costs with surgical implants when surgery was the recommended treatment. Furthermore, outcomes of patients who had been recommended surgery and underwent non-surgical treatment were similar at 12 months.33 Another potential solution is revising funding rules for procedures whose effectiveness is not supported by current evidence. Recently, the Australian Government revised its funding rules for several spinal surgery procedures. From November 1st 2018, Australian Medicare will no longer fund spinal fusion surgery for uncomplicated LBP.36

Effective approaches to tackle overuse of unwarranted spinal imaging have recently been highlighted.37 The development of a clinical decision support for hospital-based physicians requesting imaging and the use of targeted reminders to primary care physicians reduced imaging requests by 36.8% and 22.5%, respectively. A more recent study showed that restricting reimbursement for imaging requests for non-serious LBP reduced lumbar spine radiograph and CT scans in primary care by 28.7%.38 In contrast to these findings, interventions aiming at educating clinicians and disseminating guideline recommendations were not effective in reducing overuse of imaging. These findings suggest that efforts to reduce overuse of imaging should focus on changing organisational aspects.

The current scenario indicates that clinical pathways for LBP in Brazil must be rethought. The time has come to promote rational use of health services, as well as to improve quality and access to health care.15 Promoting a stepped care approach, by increasing the role of primary care in managing LBP, is likely to be beneficial for patients and the Brazilian health system. In Canada, the creation of the Saskatchewan Spine Pathway39 aimed primarily at strengthening primary health care management of LBP. In addition, it also provided tools to improve coordination of care across levels of healthcare (e.g. unified medical record). That is particularly relevant for Brazil, where referral and counter referral across levels of healthcare is often poorly implemented.40 In the UK, the STarT Back model of care, which proposes different management strategies in primary care according to the patient's prognosis, has shown benefits in reducing disability, promoting early return to work and cost savings compared to usual care.41,42 Nevertheless, an attempt to implement the STarT Back model of care in the U.S43 has failed to replicate the findings from the UK trial,41 and had no effect on patient outcomes or healthcare utilisation. In Brazil, the STarT Back tool had poor prognostic ability when used in emergency departments44 and physical therapy clinics.45 Nevertheless, these studies found that stratifying patients after 6 weeks from baseline improved the prediction of clinical outcomes. The implications of these findings should inform future implementation studies.

Payment models are an important barrier preventing people with LBP to have access to appropriate care.15 Models of payment based on the quantity of services rather than the positive effect these services might have on patient outcomes are common in Brazil. Private health insurers in Brazil often pay for expensive and ineffective procedures (e.g. fusion for persistent non-specific LBP), but limit access to effective and cost-effective treatments (e.g. supervised exercise therapy46 and cognitive behavioural therapy47).

Different health professions have long invested in aggressive professional advocacy strategies to convince patients and policymakers about their value in managing LBP. Nevertheless, effect sizes of interventions for LBP are often similar regardless of who delivers treatment,48 and findings from randomized controlled trials testing interventions delivered by different professions in people with LBP have mostly revealed comparable if not identical results (e.g. spinal manipulative therapy performed either by physical therapists, chiropractors or osteopaths).49,50 Professional disputes do not serve patients well and ideally guidelines should be ‘non-denominational’ but focus on the care that is needed rather than who must provide the care.12 LBP research must also shift its focus from specific interventions to treat LBP, towards the development of models of care for LBP that deliver the appropriate advice and/or care at the appropriate time. As well as re-evaluating the current models of care in both the public and private health system, this may also include consideration of strategies that promote healthy lifestyles and tackle social inequalities that contribute to the burden of LBP in Brazil.12

Work is an important determinant of health; unemployed people report poorer health and higher risk of early mortality.51 A number of risk factors for work disability due to LBP have been highlighted, including physical job demands, psychosocial factors, work organisation support and worker beliefs and attitudes.51 There has been an increase in rates of informal employment in Brazil,52 specially in people with lower socioeconomic status. Estimates from 2018 show that currently 10.7 million people in Brazil are working in the informal sector.52 That represents increased weekly working hours above of that regulated by the Consolidation of Labour Laws, absence of social security protection and poor employment conditions and increased work disability.53 Stimulating the employment in the formal sector is a necessary measure not only to benefit Brazil's economy but to improve the population's health.

Evidence to support some workplace interventions to reduce time lost off work, improve work functioning and costs have been recently summarized by a systematic review.54 For musculoskeletal conditions, there is evidence to recommend multi-component interventions that include at least two of the following components: health service-focused (e.g. cognitive behavioural therapy); service coordination (e.g. development of return to work plans and case management); and work modification interventions (e.g. modified working hours, worksite adjustments).54

Misconceptions about LBP are a worldwide problem, and are common in Brazil as well. People are exposed to misleading information about risk factors, prognosis and effectiveness of treatments for LBP on a daily basis from advertisements and media. People with LBP usually have negative perceptions about the prognosis of pain and perceive their lumbar spine as vulnerable, a belief that triggers avoidance behaviours as a means to protect the spine.55 This in turn can further contribute to the cycle of increasing disability. Misconceptions are not exclusive to patients; they are often perpetuated by health care professionals who advise patients to rest, avoid movement and stay off work for prolonged periods.56 For example, compared with Australian physical therapy students, Brazilian students more strongly agree that having persistent LBP justifies disability and activity.57 Even if health professionals were always proficient in addressing LBP misconceptions during clinical encounters, this is unlikely to be enough to influence societal beliefs.

It may also be important to address misconceptions before the onset of LBP. One alternative is to tackle misinformation with extensive involvement of the mass media. Brazil has been successful in promoting mass media campaigns on several sensitive topics like tobacco cessation, family planning, control and prevention of HIV/AIDS and oral rehydration for diarrhoea in the past.1 Well-funded mass media campaigns, following successful models implemented in other countries,58 have the potential to shift population beliefs and dispel myths such as that LBP should be intensively managed and that high-technology solutions represent the best care available.58

There is an urgent need for high-quality data on LBP in Brazil. For example, epidemiologic data should be based upon clear and precise case definitions such as the standardized ones developed by international consensus.59 Furthermore, it is currently unknown what the patterns of practice of health professionals involved in LBP care are. Understanding patterns of practice are necessary to identify and address drivers of unwarranted clinical variation (i.e. variation that can only be explained by differences in health system performance). These studies could form the basis of clinical care standards that would need to be implemented across the country to optimise care and outcomes for people with LBP.