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Low Back Pain Guidelines Not Always Followed By Clinicians

June 12, 2015
A patient tweaks their low back, do you order tests or treat symptomatically? Your decision may depend on your gender.

When a patient hurts their back, they look to their doctor for help. But the advice they get may depend on the gender of the clinician—and may not following standard guidelines.

According to a new study, clinicians often go against standard guidelines for treating low back pain.1 For instance, male doctors were more likely to refer a patient to a specialist, while female doctors were more likely to recommend various pain relief therapies. But in both cases, doctors weren’t following recommended procedure, which could worsen, not curb, the pain.

“Low back pain is a very large and costly problem,” said Shira Schecter-Weiner, PhD, an associate professor at Touro College's School of Health Sciences, in a press release. “We have many guidelines that can help us understand how to manage this common problem, in an effort to optimize the outcome for the patient in the least expensive way possible, and the guidelines are not being followed as they should be.”

Survey of Primary Care Doctors

The study sampled 284 primary care doctors (50% men), who practice at 5 leading New York City hospitals. The doctors were given a hypothetical scenario, where they had to decide how to treat a patient suffering from acute low back pain that appeared to be nonspecific. The study found:

  • Male doctors were 10 times more likely to refer the patient to an orthopedist
  • Male doctors were 2.5 times more likely to refer to a physiatrist, or physical therapist.
  • Female were more likely to prescribe medications (like muscle relaxants), thermal treatments, and spinal manipulation.
  • Female physicians were also more likely to prescribe x-rays or CT scans.

Too Many Specialists, Too Many Meds

Visits to specialists, multiple medications, x-rays, physical therapy—these are all medical solutions that sound useful, in theory, but when it comes to nonspecific back pain, patients need support, not prescriptions, said Dr. Schecter-Weiner.

While some cases of back pain, like spinal stenosis or a herniated disc, do require more attention, benign back pain is a normal problem that most adults will have to deal with, and most times, it can be fixed with simple solutions: better posture, self-care, core strengthening, NSAIDs, and some time and patience.

“We understand that most back pain is a natural benign condition, and part of the adult experience, as most adults [8 out of 10] experience it in their lifetime,” Dr. Schecter-Weiner said. According to the study investigators, clinicians should be telling patients to take care of themselves and stay active—bed rest is counterintuitive when it comes to nonspecific back pain.

“We are conditioned to believe that rest is important when something hurts. However, with nonspecific back pain, we have learned through many studies, that the opposite is actually true –it is movement and activity that can help the back to heal,” said Dr. Schecter-Weiner. “While activities during a painful episode may need to be modified, the person with low back pain should be encouraged to stay as active as they can tolerate.”

If a patient needs some pain relief, doctors should advise safe over-the-counter solutions, such as acetaminophen or a non-steroidal anti-inflammatory drug (NSAID), like aspirin or ibuprofen.3 If the pain persists, patients could try out some kind of secondary treatment, like spinal manipulation, acupuncture, yoga, or massage therapy, but these aren’t the first line of defense, noted the investigators.

But doctors not following clinical guidelines or the most cost-effective methods isn’t anything new, according to Michael R. Clark, MD, MPH, MBA, Director of Johns Hopkins University’s Pain Treatment Program in Baltimore, Maryland.

“I'm sure there are lots of reasons (why), but I think it's a function of habit,” Dr. Clark told Practical Pain Management. Doctors can be trained to use methods differing from formal guidelines, or they may be simply more skeptical of the latest research.

And something obvious: a doctor can have his or her own opinions about how to treat a patient, regardless of what guidelines recommend. While Dr. Schecter-Weiner said this may not lead to the most cost-effective solutions, what costs less may not be what works best, said Dr. Clark.

“Our duty is to take care of patients not to save money. That's how we've gotten into all kinds of ethical and financial scandals. Your patient wants to know you are on their side not someone else's,” he noted.

“If two therapies are truly equivalent but cost differently, then that’s fine, but the practice of medicine rarely affords us such clarity,” concluded Dr. Clark.

Humoring the Pain

Is there a point when doctors are doing too much, though?

For years, doctors have been investigating how a person’s perception of pain can be influenced as much by what’s going on in their heads as what’s going on in their bodies. According to Dr. Schecter-Weiner, too much treatment may be stemming the pain, not stopping it.

“There is evidence to suggest that the more we medicalize the problem, by ordering unnecessary tests, providing unnecessary care, and over-prescribing excessive amounts of medication, the more the person believes that something must be wrong—otherwise why all the interventions?” In reality, over-treating the pain could be prolonging it, noted Dr. Schecter-Weiner. Acute back pain resolves itself, but chronic pain goes on indefinitely, and how a doctor treats the pain seems to be playing a role in this.

“Once a person believes something is wrong they act the part—either by taking on the role of patient with family, friends, and co-workers and/or by seeking more and more health care to ‘cure’ their painful back," she noted.

"Nobody is proposing under-treating those patients who require or we suspect require diagnostic tests, procedures, interventions, and medications. What is being advocated is not making patients out of healthy people with, what in most people, is a self-limiting painful condition,” concluded Dr. Schecter-Weiner.

The pilot study was funded by the New York and New Jersey Education Research Center, sponsored by the National Institute for Occupational Safety and Health (NIOSH). The study was presented at the Touro College Research Day in April. The authors reported no conflicts of interest.

Last updated on: July 2, 2015
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