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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Chronic Low Back Pain: Can We Find a Treatment Consensus?

Arriving at a true consensus remains tricky and perhaps impossible. Experts offer their perspective on the "why" behind this standstill.
Pages 29-31

Generating clinical guidelines for treating CLBP, therefore, has become a nearly impossible task. Experts from various specialties offer their perspective on the why behind this standstill.

Background

As a leading cause of job-related disability in the United States, chronic low back pain places a substantial burden on individual quality of life as well as costs to society. According to NIH, about 80% of adults at some time in their lives will experience low back pain. Although most low back pain is acute and of limited duration, chronic low back pain (CLBP) with persistent symptoms at 1 year occurs in about 20% of people with initial acute pain.1

The cost of this is enormous. A systematic review of US spending on healthcare between 1996 and 2013 found that, after diabetes and ischemic heart disease, low back and neck pain accounted for the highest healthcare spending at an estimated $87.6 billion. In addition, along with diabetes, spending on low back and neck pain increased the most over the 18 years by an estimated $57.2 billion.2

Generating clinical guidelines for treating CLBP has become a nearly impossible task. The multitude of guidelines that do exist largely focus on different etiologies of low back pain, various interventions, and other tailored recommendations. (Image: iStock, OpenLook Design)

Unknown Causes Lead to Ill-Defined Guidelines

Epidemiological data from the most recent National Health and Nutrition Examination Survey associated key variables with CLBP prevalence, including older age (50 to 69 years), less than high school education, yearly household income (under $20,000), medical comorbidities, sleep disturbance, depression, and income from disability.3

Determining the actual prevalence of CLBP, however, remains elusive. Part of this is because pain is a symptom, not a disease; tracking the prevalence of CLBP is murky given its varying definitions and equally varying assessments.3 Further complicating things is the growing understanding that chronic pain in general can become a complex condition itself, involving the central nervous system and persisting without identifiable anatomic pathology.4

Generating clinical guidelines for treating CLBP, therefore, has become a nearly impossible task. The multitude of guidelines that do exist largely focus on different etiologies of low back pain, various interventions, and other tailored recommendations. A few comprehensive guidelines attempt to provide a multidisciplinary scope of the problem, including those from the American College of Physicians, the UKs National Institute for Health and Care Excellence (Low Back Pain and Sciatica), and the North American Spine Society (NASS), which just published its Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care in January 2020.5-7

But arriving at a true consensus or even a best evidence-based guideline remains tricky and perhaps not doable or even the right aim. Below, experts from various specialties offer their perspective on the why behind this standstill, including Eugene J. Carragee, MD, of Stanford University; Steven Cohen, MD, of Johns Hopkins School of Medicine; Chad Cook, PhD, of Duke University School of Medicine; Oren Gottfried, MD, of Duke University School of Medicine; and William Sullivan, MD, of NASS.

 

What the Experts Do Agree On:

1. CLBP is a heterogenous condition with multiple potential pathologies

For all of the experts weighing in on why there is a lack of consensus on CLBP guidelines, a core shared reason is the heterogeneity of a condition that is more of a symptom than a disease and one that lacks a clear etiology for many if not most cases.

Chad Cook, PhD, program director of the Duke Physical Therapy Program at Duke University School of Medicine, underscored that 80% to 85% of all low back pain is non-specific, cannot be linked to a biological origin, and is often influenced by psychological and social factors. “Lower back pain is not a single entity, is heterogenous with probably 20-plus phenotypes, and it is about matching the right treatment to the right person, and we haven’t done that yet,” he told PPM. Although Dr. Cook argues that most guidelines have more consistencies than variabilities in terms of recommending things like physical activity, limited bed rest, and limited opioid use, he highlighted that the unknown origin of low back pain for many people is a major reason for the “unwarranted variation in treatment recommendations.”

William Sullivan, MD, president of NASS, also stressed the difficulty of achieving consensus around a guideline for CLBP given its heterogeneity. Although the multidisciplinary, evidence-based newly published 2020 NASS guideline strives to provide a larger perspective to lower back pain, he emphasized that the guideline does not offer a treatment algorithm given the lack of singular approach to treating CLBP. “Back pain is a symptom and not a diagnosis, so it is important to take an individualized approach to what the problem is,” he said.

Offering a neurosurgical perspective, Oren Gottfried, MD, also from Duke’s School of Medicine, highlighted the difficulty for spine surgeons to use guidelines for CLBP pain given its multiple etiologies. “Even as a spine surgeon and seeing the anatomy first-hand, we really don’t clearly understand low back pain and that term is quite vague to us,” he said. Dr. Gottfried added that he thinks it is easier to follow a guideline when there is an anatomic area that needs to be corrected to reduce pain versus for those patients who may have some degeneration without any major or critical instability, deformity, or pinched nerve. When he sees the latter type of patient, he refers them to guidelines on non-operative options.

Eugene J. Carragee, MD, an orthopedic surgeon at Stanford University, who previously served as editor of Spine Journal, said he believes the available guidelines are pretty well defined for patients with clear pathologies, such as infections, tumors, instability of the spine, or spinal stenosis, but these patients, he emphasized, comprise only a small proportion of people with CLBP. For many patients, low back pain can often be linked to socioeconomic factors. “Once you’ve ruled out serious pathology, it is important to step back and take a look at the patient’s social, economic, and emotional situation as that is where the issues are,” he said.

2. Current Guidelines Offer Variable Quality and Often Reflect the Authors Views

For Steven Cohen, MD, a professor of anesthesiology and critical care medicine, and director of medical education in the pain division at Johns Hopkins School of Medicine, a major challenge to arriving at a consensus on guidelines is the often poor quality of evidence in many published recommendations. As chair of two consensus guideline committees (including the pending international consensus guidelines on Lumbar Facet Block and Radiofrequency Ablation), he noted the lack of reliable, widely accepted means to identify pain generators for lower back pain. “MRI is over-used and relatively non-specific, while ‘diagnostic’ injections are associated with false-positive and false-negative results,” he said. Dr. Cohen further noted that typical quality rating scales, such as the Cochrane Risk of Bias, often referred to in guidelines on low back pain focus on methodological quality instead of technical quality (eg, on selection of appropriate patients with specific pathology, and performing interventions in the correct way).

Dr. Sullivan agreed that the different methodologies used in guidelines are one of the biggest challenges for clinicians. “When you start talking about getting consensus statements on chronic low back pain, it is really about what is included in questions asked, the sources used, and the complexity of what is meant by ‘low back pain,’” he said.

A further problem with the guidelines themselves is that they often present their authors’ points of view. “Guidelines [specifically monodisciplinary ones] reflect the people who wrote them, and tend to support their area of interest,” said Dr. Cook. Dr. Cohen put it this way. “Psychologists may overlook anatomical considerations, while surgeons and interventionalists may fail to appreciate the extraordinary influence psychological factors play in chronic pain,” he said.

 

3. The Payer Issue

A related problem is the underlying issue of reimbursement. “I think there is a bias to pay for expensive interventions like surgery and less is done for prevention or non-operative measures like PT, therapeutic exercises, and chiropractic care,” said Dr. Gottfried. “What is paid for is usually the huge intervention of surgery, while an increased emphasis on long-term outcomes and reducing back pain and disability across the population at the lowest cost should be the target.”

Dr. Carragee also emphasized the role money plays in spine care. “Next to cardiology, spine care is the biggest medical boon in the country,” he said. “It is an enormous business with a nearly inexhaustible patient supply.”

Dr. Cook, however, pointed out that most of the recent changes in treating CLBP have been driven by insurance companies or payers pushing back on reimbursing unnecessary interventions. “We are seeing a reduction in approval of spine surgeries or invasive interventions, especially early, for those who really don’t need that approach,” he said. He added that he thinks there is a move toward a consensus on treatment for CLBP but noted, “we aren’t there yet.” 

 

See how experts address a hypothetical low back pain case in our roundtable.

Last updated on: April 20, 2020
Continue Reading:
Experts Roundtable: Finding a Bottom Line in Back Pain Care
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