Treating Low Back Pain: More Evidence That Less Is Better

Low back pain (LBP) is one of the most common reasons patients see primary care physicians. Patients with LBP frequently believe that there is an identifiable cause of the pain that needs to be discovered and repaired. They may feel they are receiving second-rate care if their physician tries to disabuse them of this belief.

Three new studies contribute to the already large body of research that demonstrates that the workup and treatments many patients undergo for LBP are often unnecessary and frequently provide limited benefits.

The first study, in the Journal of the American Medical Association,  examined acute LBP without the presence of radiculopathy in more than 5200 patients aged 65 years or older who went to their primary care physicians for this problem.¹ It sought to determine whether outcomes after 1 year would be better for patients who underwent diagnostic imaging (ie, CT, MRI, and plain x-ray films) during the first 6 weeks after the initial complaint than for those who did not undergo imaging during that period.

At the end of 1 year, no difference was found, on a measure of pain-related disability, between patients who underwent any of the tests during the initial period and those who hadn’t.

The second study is a meta-analysis of 14 trials with a total of more than 4800 patients with acute (less than 6 weeks’ duration) and subacute (6 to 12 weeks’ duration) LBP for whom the primary intervention was an educational program focused on reassurance.² The educational messages sought to: diminish concerns that the pain might represent a severe illness; reinforce the nonspecific nature of LPB and that extensive evaluations are unnecessary; and encourage patients to stay physically active.

The primary outcome measure was number of follow-up visits with the primary care physicians for the pain. Most of the studies lasted for a year and found that over this period, patients who participated in educational programs had a reduced number of visits compared with those who didn’t participate in the programs. The benefit appeared greater in those studies where it was the physician rather than a nurse or a physiotherapist who provided the education.

The third study compared symptom relief and functional improvements in patients with lumbar spinal stenosis who received physical therapy (PT) with those who had surgery for this problem.³ After 24 months, no differences between the two groups were found on either measure.

So what are the take home messages from these studies? I find 3.

The first and most obvious one is that for many cases of LBP we should be more judicious in the use of tests and surgical interventions. This supports recommendations based on earlier studies that demonstrated we don’t need to rush in every patient with LBP for radiographic studies. We know that in the absence of red flags such as signs of infection, recent trauma, unexplained weight loss, paralysis or paresis, or worse pain on lying down, it is highly unlikely that there is some severe medical process causing the pain that requires acute attention.

The second is that we need to talk with patients and give them a true picture of LBP to help alleviate their worst fears and concerns. I know from personal experience that many patients with LBP who have been seen by multiple physicians have never been provided with a straightforward discussion of what we know about LBP.

The third is that even where there appears to be an identifiable cause of the pain, as in a case of spinal stenosis, there are still many cases where patients do not need surgery to repair it in order to improve.

The overriding question is, if we know these conservative measures work, why aren’t they used more often? 

Some may say about testing that physicians are afraid that if they don’t test, they will miss some serious underlying disorder, even though that would be extremely unlikely if they know to look for the red flags noted above.

Also, concern about overlooking  an underlying disease process doesn’t explain why physicians aren’t willing to spend more time educating their patients with LBP or why so many patients undergo surgery for LBP before having this or other conservative treatment modalities such as PT.

Unfortunately, I think the answer lies in how compensation for health care is handled in this country.

Physicians are paid little if anything for talking with their patients so doing so doesn't help pay the practice bills. It also takes much less time to prescribe a radiographic study than it does to counsel a patient especially if the patient is convinced that the study is necessary. And, of course, hospitals, where many of those MRI machines are located, look favorably on physicians who refer patients.

Compensation enters the picture, too, when considering surgery versus PT to treat spinal stenosis. A great deal of money can be made from the former compared with the latter. When done correctly PT is essentially side-effect free while surgery always carries some risk of adverse events including very severe ones, so it would be logical to try the PT first. Other conservative therapies also carry minimal risk of adverse events and are often as beneficial as surgery for LBP. In few cases is there a need to rush to the operating room before trying them.

References:

1. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015;313:1143-1153. http://jama.jamanetwork.com/article.aspx?articleid=2203801

2. Traeger AC, Hubscher M, Henschke N, et al.  Effects of primary care-education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA Intern Med. Published online March 23, 2015. doi:10.1001/jamainternmed.2015.0217 http://archinte.jamanetwork.com/article.aspx?articleid=2204032doi:10:1001/jamainternmed.2015.0217

3.  Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spine stenosis: a randomized trial. Ann Intern Med. 2015;162:465-473. doi:10.7326/M14-1420  http://annals.org/article.aspx?articleid=2214174