The Low Back Pain Paradox: Part II

In Part I of this series, I discussed a few of the reasons that make low back pain such a paradox in health care. The scientific research clearly indicates a disconnect in the health care world - a disconnect between commonly-held beliefs about low back pain, and the evidence that refutes them.

When 97% of low back pain patients present with "mechanical low back pain" - with the majority of those having no specific patho-anatomical diagnosis - we are forced to re-consider the context in which we view the problem itself. This is the only way that we will find solutions and not just stop-gap measures to satisfy the status quo.

So with solutions as our goal, let's take the next step in understanding the paradox. We'll carry on from patient access, head into assessment, and end up with the utilization of services once the patient has access to care.

Safety: The current gatekeepers always manage to conjure up "reasons" why the health care system should limit patient access to care to just a select few practitioners. What about patient safety?

In many states (including Texas), a patient with low back pain has access to care from a massage therapist, or an acupuncturist, or any one of countless clinicians. Gatekeepers have never taken issue with this. Safety? Not an issue. But suddenly, a patient directly accessing a physical therapist for evaluation and treatment of their low back pain becomes a patient safety issue in their eyes. Seriously?

There are plenty of countries in which patients have direct access to care from a physical therapist - and have done so for decades without adverse patient safety issues. There has yet to be any data published - in any state (or country, for that matter) - that supports the supposed patient safety issue. So let's put this excuse to rest, once and for all. It’s old, tired, and a blatant fallacy.

If we are going to discuss patient safety, then I would suggest we should review the statistics on spine surgeries in the United States. Consider the 20,000 lumbar spinal fusions performed in the US annually - #1 in the world. We are also #1 in the world in failed back surgeries. There are 8 times as many spinal surgical procedures per capita in the the US than in Britain. Keep in mind that the UK has a health care system rated higher than the US (#18, versus #38 for the US). Based on the data, we have a simple conclusion: either the US is home to the "problem" spine, or spinal fusions are being over-utilized. Plain and simple. One has to wonder which patient safety issues we should really be discussing when it comes to low back pain. But I digress.

Lesson Learned: Providing a patient with low back pain greater access to care has not created - and won't create - an increased safety issue. There is already a multiple-decade global precedence for this to occur successfully and without adverse effect in other first-world nations.

Imaging: What about imaging and MRI? Shouldn't a patient have all of these tests done before initiating care? Does a patient require imaging studies to make a specific diagnosis of their low back pain?

There is not one clinical guideline that I am aware of that advocates the use of x-rays, CT scan, or MRI as a first line of assessment in the diagnosis and treatment of low back pain.

Hold on a second here. How many patients are told at their initial examination that imaging is the first assessment they need? Yes, I thought you might say that. A whole bunch of them.

We would like to believe that imaging provides us with more detail on the problem. However, the scientific reality is clear: about 70% of people will have an abnormal MRI - yet absolutely no symptoms or history of low back pain. If someone tells you they have an abnormal MRI, what does it tell us about the presence or absence of symptoms?

Lesson Learned: Imaging studies serve limited value in the initial assessment of the patient with low back pain. Fortunately, clinical guidelines advise the usage of “low tech” history and physical examination procedures - the cornerstone of many clinical approaches including physical therapy. Can't prescribe an MRI? No worries - most patients with low back pain won't require it when they enter the health care system in the first place.

Utilization: This is, without a doubt, one of the greatest problems in health care. The world of low back pain is no different here - it is just reflective of the greater health care woes.

Regardless of what clinical guidelines suggest, we continue to see patients with low back pain referred for x-ray and MRI at the time of their initial physical examination. Are clinicians just not reading the studies? A conservative estimate for the cost of an MRI is $1500. But what happens when clinical guidelines counter what is currently a healthy revenue stream for some?

If we return to the issue of spine surgery, you will find a cost explosion - with little return on investment for many:

"For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy."(2)

As Chou et al also noted in a separate review:

"Few non-surgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials" (1).

These include local injections, prolotherapy, epidural steroid injection, facet joint injection, sacroiliac joint injection, and chemonucleolysis - among others.

Here's a novel thought - what about utilizing low cost alternatives such as physical therapy? Here is but one example:

"This study indicated that EA [early access] to physical therapy resulted in greater improvement in perceived pain at 6 months compared to later access. In this study, EA to physical therapy could be introduced by reorganization without additional resources." (3)

Add to this the experience gained at Virginia Mason Medical Center. When a patient with low back pain was seen by a physical therapist first, the overall cost of care per patient dropped by 50%.

Lesson Learned: The health care system over-utilizes the expensive procedures while under-utilizing (or preventing access to) the cost-effective procedures. The loser in that battle? The patient, of course.

The Dilemma: After two posts on the low back pain paradox, I am exhausted. Why? The degree of denial of science and evidence that runs rampant. The data on low back pain has remained considerably consistent for two decades. Yes, new research expands our understanding of the problem. But the data and evidence is being ignored, and while doing so, the problem is getting larger. In the United States, approximately $26 billion was spent in 1998 treating low back pain. At the time, that amounted to 2.5% of all health care expenditures for that year. And it is only getting worse.

We must do what is right for patients. But in order to do so, we simply cannot keep denying the evidence for the sake of clinical or political agendas.

Part III will look at the evidence-based solutions to the paradox.

References:

1. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. (2009). Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine; May 1;34(10):1078-93. doi: 10.1097/BRS.0b013e3181a103b1.

2. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. (2009). Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine; May 1;34(10):1094-109. doi: 10.1097/BRS.0b013e3181a105fc.

3. Nordeman L, Nilsson B, Möller M, Gunnarsson R. (2006). Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial. Clin J Pain; Jul-Aug;22(6):505-11.

Photo credits: Davide Restive