Incorrect treatment of back pain is on the rise

New research shows that physicians are increasingly choosing the wrong treatments for back pain, while physiotherapy referrals remain stagnant.

The well-established clinical practice guidelines for managing and treating back pain support the use of non-opioid pain-killers, avoidance of imaging, and the use of physiotherapy including exercise therapy.  For the latest research on which lower back pain therapies appear work, and which don’t, check out our new post: “New research for preventing recurrence of lower back pain: 2 do’s and 5 don’ts“.

However, a recent study concludes that despite abundant clinical guidelines advocating these methods of care, physicians are increasingly relying on narcotics, CT (computed tomography) and MRI (magnetic resonance imaging) scans, and referral to other physicians (presumably for consultation for injections or surgery) (ref1).  This growing trend negatively impacts both patient quality of care, and overall health care spending.

The authors of this study examined nearly 24,000 physician visits for spine related issues from 1999 to 2010 in the United States. Depressingly, the authors conclude that over this decade not only did narcotic drug use increase from 19.3% to 29.1% in spite of guidelines advising against its use for treating back pain, use of the recommended non-steroidal anti-inflammatory drugs (NSAIDS) or acetaminophen actually decreased from 36.9% to 24.5%.  Similarly, physician referrals to other physicians increased from 6.8% to 14% (a practice not supported by the guidelines) whereas referrals to physiotherapy for back pain treatment (which is supported by the guidelines) remained unchanged. Finally, CT and MRI scans increased from 7.2% to 11.3%, in contradiction of best practice guidelines.

Figure 1: Patient referral and drug prescription trends over time show an unfortunate stagnation in physiotherapy (‘physical therapy’) referrals and decreased NSAID / acetaminophen prescription in favour of incorrect clinical practices such as increased physician referrals and narcotic prescription. (ref 1)

Although these results come from a large American study, it is plausible that they are broadly generalizable to Canadians as well. The study’s conclusions were found true even after controlling for a wide range of confounding variables including age, sex, ethnicity, geographic region and metropolitan location, symptom duration, visits to primary care physicians versus non primary care physicians, etc.

Why don’t physicians follow clinical practice guidelines for back pain?

The obvious answer is that clinical practice guidelines alone do not inform physician practices. A variety of other factors could contribute to this behavior including: best-practice guideline confusion arising from a flood of low-quality back-pain studies, reduced appointment times resulting in less comprehensive evaluations and treatments, stronger (yet misguided) patient self-advocacy, increased availability of imaging, etc.  It has been suggested by health policy researchers that it takes on average 17 years for conclusions from clinical trials to be integrated into clinical practice (ref2).

Effective management and treatment of back pain is necessary to improve patient quality of life and productivity, as well as to address the growing concern of escalating health care costs.  Ensuring that clinical practice guidelines are effectively implemented is a health care priority.

References

1. Mafi, J.N., McCarthy, E.P. et al. Worsening trends in the management and treatment of back pain. JAMA Intern Med. [published online July 29, 2013].
2. Crossing the Quality Chasm: A New Health System for the 21^st Century. Institute of Medicine (IOM). Washington, DC: National Academy Press; 2001.