Referral Patterns in Low Back Pain Patients

This study examined how 98 cases of new onset, uncomplicated low back pain was generally handled in patients with workers' compensation claims.

Over half of the cases were initially seen in emergency rooms or urgent-care facilities. The authors hypothesize that this is due to patient preference, or an employer's desire for employee to receive prompt care, or limited availability of low-cost, easy-access centers for work-related injuries. 24% of these patients then had their follow-up care in the same urgent care centers. This is an extremely inefficient and expensive way to treat the onset and course of low back pain.

The authors seemed surprised that just a few patients were seen on intake by a "occupational medicine" (OM) specialist. "The main provider of care was again most likely to be a primary care physician (47%), followed by non-OM specialists (23%) and OM specialists in 13% of the cases. Of the original 98 patients, 52% were referred to a specialist. Of the 35 referrals to surgeons only 2 did have surgical intervention. The authors estimated the median number of visits to all providers was five.

The authors conclude that the handling of uncomplicated low back pain cases was ultimately not cost effective:

"As noted, many of the utilization and referral practices described herein can reasonably be expected to increase the costs of managing such LBP claims, and in multiple published reports, they have not been shown to demonstrably increase efficacy of treatment."

The entire study was focused not on the effectiveness of a particular type of treatment and did not study outcome. The focus was on costs and "system efficiency." This is not surprising, as the study was funded in part by the Liberty Mutual Insurance Company and a center that that have as part of Harvard University.

Tacci J, Webster B, Hashemi L, Christiani D. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. Journal of Occupational and Environmental Medicine 1998;40(11):958-963.

Controlling Lumbar Flexion to Reduce Low Back Pain

This study attempted to reduce patients' nonspecific low back pain without medication, manipulation, or surgery. They tested the prolonged effects of controlling lumbar flexion (forward bending) movement in the morning.

The authors emphasized to the subjects that the first two hours after rising were the most important—they should not bend, sit, or squat—and to attempt to keep a straight back during that time of the day. Squatting or kneeling was permissible for the remainder of the day, but bending was to be avoided.

The authors compared the results to a control group. The control group was advised to perform six commonly prescribed exercises, such as pelvic tilt, hamstring stretch, and side leg raise, which have been found ineffective in reducing low back pain.

Subjects in both groups were asked to keep a daily dairy that answered the following questions:

1. How would you rate your back pain today on a 0 to 10 scale in which 0 is "no pain" and 10 is "pain as bad as it could be"?
2. Did back pain prevent you form performing your usual work activities today (work, school, or housework)? Yes or No?
3. Did back pain prevent you from participating in any recreational, social, or family activities today? Yes or No?
4. Did you take any medication today (including over-the-counter medication)? Yes or no? If so, what kind?

Each week participants mailed in their responses. The questions were designed to measure pain intensity, disability, impairment, and medication usage.

The study began with 116 subjects, but due to the demanding regimen many participants dropped out; when they entered phase two, 85 subjects were involved. The treatment group had 24 subjects, and the control group had 36 patients.

Thirty�five percent of the subjects in the treatment group reduced their pain by 50% after six months of flexion control. The following chart shows the percentage decrease the patients experienced.

Overall the findings were successful, and patients who continued for six additional months reduced pain further. One additional benefit of the exercise was that it was effective for both men and women and for patients older (46-60) and younger (30-45). Also:

�"Perhaps somewhat surprising, but also encouraging, is the finding that subjects with high psychological overlay benefited as much as those with low psychological overlay, and subjects with leg pain benefited as much as those without leg pain. The only subjects who did not benefit as well were those who performed heavy physical work."

Snook SH, Webster BS, McGorry RW, et al. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998;23(23):2601-2607.

Conservative Treatment of Lumbar Stenosis Effective

This study followed patients diagnosed with lumbar stenosis. Surgery was performed on 440 of these patients, and 57 were treated with conservative, but unspecified, care. Both groups were re-examined 4 years after the start of treatment.

The study found that when the patients were matched for sex, age, objective findings, and symptoms, there was no significant difference in outcome between the two groups. The study did find that operated men fared better than non-operated men, but concluded, "conservative treatment of lumbar spinal stenosis should be considered for the patients with moderate stenosis.

Herno A, Airaksinen O, Saari T, Luukkonen M. Lumbar spinal stenosis: a matched-pair study of operated and non-operated patients. British Journal of Neurosurgery 1996;10(5):461-465.

Clinical Practices in Low Back Pain Management

The purpose of this study was to assess both how health care providers manage new onset uncomplicated low back pain (LBP) in Worker's Compensation cases and to determine which methods increase costs. 98 LBP subjects and their treatment courses were evaluated for one year. Subjects did not have a pre-existing history of LBP or any concurrent injuries or conditions.

The following table summarizes the methods practitioners commonly use to manage LBP:

The authors conclude these findings suggest overuse of diagnostic and treatment modalities. The authors claim diagnostic imaging was overused in terms of the total number, and also the time frame in which the x-rays and MRI's were performed:

"While plain films are not recommended within the first month of clinical management except under certain circumstances, over half of the patients in the sample were x-rayed within the first month, and 38% were ex-rayed during their first clinic visit...Such over-utilization of diagnostic test represents a clear cost inefficiency and, in the case of plain films, a potentially unnecessary exposure to ionizing radiation for the patient."

Over-prescribing expensive or habit forming medications was also of concern. The authors were surprised at the high rate of opioid analgesic prescribing—considering the uncomplicated nature of the cases at hand. All 38% of the opioid-users renewed their prescription, and the authors claim, "this duration far exceeds the recommendations of the guidelines and, it is suggested, would increase disability duration in may cases."
In summary, the authors suggest that inappropriate medical treatment may actually worsen recovery rates:

"It is of particular note that the cases were specifically selected for their clinically uncomplicated nature. As best as could be determined, the patients in this sample had no prior history of LBP and had no concurrent injuries or medical conditions that could impact clinical management. In addition, these cases were not in any way suspicious for the presence of fracture, tumor, infection, or cauda equina syndrome,, nor did they display any significant progression of their symptoms. As such, one would expect a relatively minimal intensity level for diagnostic treatment modalities. Furthermore, it would be most appropriate to consider certain diagnostic studies or treatment modalities only after a reasonable course of conservative management. Overutilization of either diagnostic or treatment procedures increases the likelihood of iatrogenic complications, is not cost-effective, and may adversely impact clinical and occupational outcomes."

Tacci J, Webster BS, Hashemi L, Christiani DC. Clinical practices in the management of new-onset, uncomplicated, low back workers' compensation disability claims. Journal of Occupational and Environmental Medicine 1999;41(5):397-404.

Chiropractic & Massage Beneficial for Back Pain

Back pain is a very common complaint, affecting up to 30% of people in the United States each year, and it is one that can be difficult to treat. Recent news has raised doubt about the effectiveness of some traditional medical responses to back pain, including surgery, pain relief supplements, and even bed rest.

A study published in May 2010 looked into the effectiveness of complementary and alternative therapies on back pain. Researchers from Harvard Medical School and Brigham and Women’s Hospital in Boston used data collected as part of the 2002 National Health Interview Study to investigate the “perceivedhelpfulness” of six treatments, including chiropractic, acupuncture, massage, herbal therapy, relaxation techniques, and yoga/tai chi/qi gong.

Chiropractic and massage were the two most common treatments that participants sought out. Although nearly half of participants reported that they had turned to an alternative treatment in conjunction with conventional medicine, only a quarter of them had tried the therapy because of a recommendation from their doctor.

The researchers found that 60% of people who tried at least one of the therapies felt they had received a “great deal” of benefit from the treatment. This rate of satisfaction was highest among chiropractic patients, two-thirds of whom perceived a benefit from their treatment. Just over half of those who used massage or yoga reported that it had helped them (56%). These rates of satisfaction were lower among those who tried acupuncture (42%), herbal therapies (32%), or relaxation techniques (28%).

The researchers could not compare these results against results from nonusers of alternative or complementary therapies for back pain, and the findings are subjective. Yet their study shows that the majority of those who turn to therapies like chiropractic and massage to treat back pain can derive substantial benefit.

Kanodia AK, Legedza ATR, Davis RB, Eisenberg DM, Phillips RS. Perceived benefit of complementary and alternative medicine (CAM) for back pain: A national survey. Journal of the American Board of Family Medicine. 2010 May-Jun;23(3):354-62.

Vocational Outcome of Back Pain intervention

This review article studied 40 separate studies, hoping to establish guidelines for occupational health physicians encountering low back pain. The researchers attempted to test the efficacy of different intervention treatments in terms of absence rates and duration of sick leave. Their findings:

• "Bed rest should be limited or even avoided; normal activity should be continued as much as possible."
• "If any conservative treatment for patients with acute low back pain is considered, spinal manipulation is the best option."
• "Furthermore, there are promising results for exercise and education programs, especially for intensive programs in an occupational setting."

van der Weide WE, Verbeek JHAM, van Tulder MW. Vocational outcome of intervention for low back pain. Scandinavian Journal of Work and Environmental Health 1997;23(3):165-78.