Well established guidelines for first-line treatment of back pain state that the physician should prescribe acetaminophen or a non-steroidal anti-inflammatory (NSAID) for pain and physical therapy for rehabilitation. A new study, published in the Annals of Internal Medicine, suggests that doctors are skipping these guidelines and jumping straight to the more aggressive treatments (like narcotics and imaging scans.)

See Medications for Back Pain and Neck Pain

The authors of the study, who are researchers from Beth Israel Deaconess Medical Center (BIDMC), contend that spine patient care could be enhanced and general health care costs could go down if physicians would follow the established guidelines. Lead author John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, commented:

    "Back pain treatment is costly and frequently includes overuse of treatments that are not supported by clinical guidelines, and that don’t impact outcomes. Improvements in the management of spine-related disease represent an area of potential for improving the quality of care and for potential cost savings for the health care system."

The study

The researchers reviewed ten years of outpatient data (from January 1, 1999 to December 26, 2010) from 23,918 spine patients. The patients sought treatment for back or neck pain as a primary or secondary reason for their doctor visit. Researchers did not include data from patients who were exhibiting neurologic symptoms, cancer, or fever along with their back or neck pain.

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A worsening trend

During the study period, the mean age of the patients increased from 49 to 53 years, and approximately 58% of the patients were female. Researchers evaluated how many times physicians acted against the guidelines by ordering:

  • Imaging (X-ray, MRI, etc.)
  • Narcotics (opioids)
  • Referrals to physicians (spine specialists, pain specialists)

They also evaluated how many times physicians acted in accordance with the guidelines by ordering:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen
  • Referrals to physical therapy

They found that comparing 1999-2000 versus 2009-2010 (all changes are statistically significant):

  • NSAID or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5%
  • Narcotic use increased from 19.3% to 29.1%
  • Physical therapy referrals remained unchanged at 20%
  • Physician referrals increased from 6.8% to 14%
  • The number of X-rays remained the same at 17%
  • Computed tomograms or MRIs increased from 7.2% to 11.3%

While physical therapy referrals remained unchanged, it is notable that only 20% of the patients were ever referred.

See Physical Therapy for Low Back Pain Relief

Established medical guidelines

The American College of Physicians published recommended guidelines for low back pain in 2007. Research has shown that these established clinical treatment guidelines for back and neck pain are typically successful by three months.

As noted above by Dr. Mafi, deviating from the recommendations and treating primary back and neck pain aggressively does not help the patient, and it is associated with higher medical costs. Why do you think doctors are treating back pain more aggressively now than they used to?

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