The Low Back Pain Paradox: Part I

It was once noted that "every problem contains within itself the seeds of its own solution". With that astute quote in mind, I present to you low back pain: the poster child of all of the health care system's woes and harsh realities.

A total of 31 million Americans experience low back pain at any given point in time. Low back pain affects about 80% of the population at one time or another. If you had those odds in Las Vegas, you would be making a lot of money. Quickly, I might add.

Low back pain also represents the #5 reason for all physician visits, and the second most common symptomatic reason (1,3). The scope and magnitude of the problem is significant. The estimated cost of back pain in the US exceeds $170 billion annually. Yes, billion. That puts it in the same category fiscally as hypertension and diabetes.

It doesn't take the crew of Apollo 13 to establish that yes, Houston, we do have a problem here. It is a problem that is reflective of the woes of the health care system. As goes low back pain, so goes health care costs.

Low back pain is a paradox that contains within itself the seeds of its own solution. But we need to learn from the lessons of 20+ years of spine research – and we need to do so as soon as possible. Let’s start with what may sound like the most basic of questions for patients, clinicians, and legislators: what is low back pain?

Diagnosis - Or Not? Back in 2001, Deyo and Weinstein published a review article in the New England Journal of Medicine entitled "Low Back Pain" (2). In this article, they noted that "perhaps 85% of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis". That's a lot of people. Alf Nachemson, one of the great spine researchers, once noted that "rarely are diagnoses scientifically valid" (5). Many scientists have followed him, and many have come to the same conclusion. It’s not like this is a newsflash – the research has existed for decades.

This thinking is reflected in the world of ICD-9 codes. ICD stands for "International Statistical Classifications of Diseases". The associated codes are designations given to "every diagnosis, description of symptoms and cause of death attributed to human beings". Please note the broad and non-specific "diagnoses" in the following common ICD-9 code examples:

724 Other and unspecified disorders of back

724.2 Lumbago (low back pain, low back syndrome, lumbalgia)

724.3 Sciatica

724.5 Backache, unspecified

Pretty generic, catch-all terms, no?

So tell me again, if the researchers don't feel that most patients have a specific diagnosis, then why would the clinicians?

Lesson learned: "Low back pain" as we currently know it in the scientific research is not a medical diagnosis like diabetes or hypertension. If anything, it has become a generic catch-all, simply a restatement of facts brought forth by the patient in the first 30 seconds of the subjective history. That is fine – but the scientific research should force clinicians (and patients) to change their perspective on what the problem is (or isn’t) and how to address it. That won’t be an easy or comfortable task for many.

Guidelines Are Good: Fortunately, in the world of low back pain, we have a number of well-established, science-based clinical guidelines. Fortunately (again) they are all pretty consistent in terms of what should (or shouldn't) be done in the process of assessment, diagnosis, and treatment.

Whew. We might be onto something here now.

Let's jump into the time machine and go back to 1994 to find one of the first clinical guidelines for low back pain - produced right here in the United States. It was released by the Agency for Health Care Policy And Research. At that time,

"A focused medical history and physical examination are sufficient to assess the patient with an acute or recurrent limitation due to low back symptoms of less than 4 weeks duration. Patient responses and findings on the history and physical examination, referred to as "red flags", raise suspicion of serious underlying spinal conditions ... The medical history and physical examination can also alert the clinician to non- spinal pathology (abdominal, pelvic, thoracic) that can present as low back symptoms".

With that said, only 1% of cases are considered "non-mechanical spinal conditions" (neoplasia, inflammatory arthritis, and infection) with 2% considered "non-spinal/visceral disease" (pelvic and renal organs, aortic aneurysm, GI system, shingles)(4). "Mechanical low back pain" as a differential diagnosis of low back pain (and non-specific at that) accounts for 97% of all cases of low back pain. That is a great thing - because 97% don't have those "serious underlying spinal conditions".

So how does a clinician rule out those "red flags"? By a focused history and basic physical examination procedures that are at the heart of many clinicians' current scope of practice. That includes physicians, chiropractors, physical therapists, and advanced nurse practitioners, among others.

What makes this all the more intriguing is that 35% of U.S. adults are now considered "online diagnosers". A growing number of patients are already screening themselves online. In this new digital reality, surely there are many health care providers, including physical therapists and nurse practitioners, that are more than capable of asking the appropriate questions regarding red flags?

Lesson Learned: The history and physical examination serve as the foundation for the assessment of low back pain. However, these two elements of assessment are not mutually exclusive to any specific health care provider or gatekeeper - far from it. Besides – in today’s reality, if clinicians aren’t doing so, patients will.

The Dilemma: The scientific research clearly indicates a disconnect in what the health care world believes about the patient with low back pain, and that which the science supports or refutes. Low back pain is generally a self-limiting issue prone to recurrences. Most cases are non-specific in nature and have no specific patho-anatomical diagnosis, and this is the context in which low back pain needs to be viewed.

Sadly, many clinicians (including many gatekeepers) simply won’t like that – for reasons that have nothing to do with whether it is right or wrong for the patient or the quality of their care.

There are any number of arbitrary laws nationwide - including those that limit access to care from a physical therapist - that are unsupported in the scientific literature and are simply not in the best interests of the patient with low back pain or the health care system as a whole. They developed from antiquated approaches to care, and they persist to this day.

Patients and consumers, what say ye?

Oh, but I can hear the storm brewing already. What about patient safety? What about imaging and MRI? Shouldn't a patient have all of these tests done before initiating care? More on the science behind those issues in Part II of this report.

References:

1. Atlas SJ and Deyo RA. (2001). Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 February; 16(2): 120–131.

2. Deyo RA and Weinstein JN. (2001). Low back pain. N Engl J Med 344:363-370.

3. Hart LG, Deyo RA, Cherkin DC. (1995). Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine Jan 1;20(1):11-9.

4. Kinkade S. (2007). Evaluation and Treatment of Acute Low Back Pain. Am Fam Physician. Apr 15;75(8):1181-1188.

5. Nachemson AL. (1992). Newest knowledge of low back pain. A critical look. Clin Orthop Relat Res Jun;(279):8-20.

Photo credits: Davide Restive