Acute low back painOpportunities for care (honest)

Tim Carey MD MPHDept of Medicine

Sheps Center for Health Services ResearchUNC Chapel Hill

Low back pain• 80% lifetime prevalence

• 3% of population seeks care for LBP/yr

• Average MD sees 2-4 LBP pts/wk

• Medical costs > $25 billion and rising

Back pain therapy project

TC 3-18

SCIENTIFIC INQUIRY

Hypothesis > Try to disprove

Evidence Tentatively accept

fails to < hypothesis; test

disprove > implications

Results replicated, < Refine

implications prove practical

valid > application

TOO MUCH BACK PAIN RESEARCH

Hypothesis Establish

(new test or > clinic devoted

treatment) to hypothesis

Try to prove

hypothesis <

Weak test < Proclaim fact, devise billing

offers some > code, form interest group to

support lobby for support, publicize

Figure 2. A contrast between the usual approach to scientific inquiry and too much back pain research.

Tim/pres/1/24/97(6)

Paradigms of LBP

• “Don’t worry-be-happy”

- 95% of patients with LBP recover

• “The grim slide into disability”

- High recurrence rates

- Over 1/3 of patients have chronic symptoms

TC 2-7

EXPLANATORY MODELS IN BACK PAIN

• ALLOPATHIC: RUPTURED DISC, “BLACK BOX”

• CHIROPRACTOR: SUBLUXATION OF THE SPINE

• PHYSICAL THERAPY: STRENGTH, INFLAMMATION

• PATIENT: DISC, ARTHRITIS

• SUPPLIERS: WRONG BED, WRONG CHAIR

TC 7-11

THE INJURY PARAGIGM

• IF THE BACK HURTS, IT MUST HAVE BEEN INJURED

• IF SOMETHING IS INJURED, IT NEEDS REST

• INJURIES OCCUR THROUGH SOMETHING WE (OR SOMEONE ELSE) DID WRONG

• INJURIES ARE PREVENTABLE

TC 7-10

Acute low back pain

• Affects 8% of population each year

• 40% seek care

• Second most common symptomatic reason for care seeking at primary care MD offices

• 95% functional recovery at 6 months

• Recurrence commonTC 2-9

Chronic Back Pain

• Common, morbid, expensive• Epidemiology unclear due to variable

definitions of the syndrome• 1992 estimate of chronic LBP in NC=3.9%– Functionally impairing and– >3 months in duration (or >25 episodes per year)

• 2006 estimate 8-9% using same definition• Care seeking also increased

Why are physicians uncertain?

• Voluminous data

• Limited training in LBP in primary care

• Specialists see very different diagnostic spectra from each other

• Patient expectations may not be congruent with caregiver ability to affect the natural hx of the illness

TC 7-18

What hurts?

• Discs• Annulus fibrosis• Facet joints• Muscles• Ligaments• Inter-individual variability in sensitivity to

somatic input

When to see a physician?

• Unrelenting, severe pain• Leg weakness• “Red flag’ underlying conditions• Significant trauma• Symptoms not improving after 2 weeks or so• Off work for > 5 days (variable depending on

job)

Initial evaluationLook for the “red flags”

• Weight loss• Fever• Hx non-skin malignancy• Chronic steroid use, osteoporosis• Significant trauma• Hx IVDA• Progressive neurologic deficit

Serious causes of acute low back pain

• Metastatic malignancy– Primary malignancy

• Infectious processes• Cauda equina syndrome– Central disc herniation

• Compression fracture• (Spinal stenosis)• (Acute disc herniation)

Physical exam

• Touch what hurts• Gait, observation, Waddel signs for chronic

symptoms• Straight leg raise• Knee jerk• Ankle jerk• Foot dorsiflexion• (Sensory exam)

By Gary Larson, It Came From the Far SideTC C-1

Patients Eligibility Requirements

Patients with low back pain• Age > 20 and < 75• < 10 weeks duration this spell• No previous care for this spell• No back surgery or chymopapain ever• No history of non-skin malignancy• Not pregnant• Had home telephone• English speakingNC Back Pain Project

TC 7-19

NC Back Pain Project Cohort Study Interview Schedule

Index VisitEnrolled

BaselineInterview

2 wk 4 wk 24 wk8 wk 12 wk

“All Better” At Interview

TC 6-1

Figure 1.-Cox-Model Curves of the Time from the Initial Visit to Functional Recovery among Groups of Patients with Low Back Pain Treated by Various Types of Providers. The confidence intervals overlap (data not shown), with no statistically significant differences among the six strata. Data have been adjusted for base-line differences in functional status (the Roland-Morris score), the presence or absence of sciatica, income, duration of pain before the index visit, workers' compensation status, and educational level. Because of overlap, not all of the six curves are visible

From: Carey: N Engl J Med, Volume 333(14).Oct 5, 1995.913-917

Total Outpatient Direct Medical Charges per Episode of Low Back Pain

STRATUM MEAN ADJUSTED MEAN*

Urban Primary Care $478 $508

Rural Primary Care $540 $474

Urban Chiropractor $508 $783

Rural Chiropractor $554 $611

Orthopedist $809 $746

HMO $365 $435

*Adjusted for baseline functional status sciatia, income, duration of pain, and worker’ compensation

TC 7-4

Recurrence of LBP from 6-22 Months Among Those Completely Recovered by 3 Months (N=754)

0

10

20

30

40

50

60

UrbanPrim

RuralPrim

UrbanChiro

RuralChiro

Ortho HMO

Per

cen

t R

ecu

rren

ce

Practitioner Strata No RecurrenceMild RecurrenceSevere RecurrenceNC Back Pain Project

N=137 N=54 N=72

N=166 N=128 N=157

p = 0.01

Carey Slides 13/Kathë

Imaging procedures• Who needs radiographs (x-rays)?• High vs. low risk patients.• Non-specific ‘wear and tear’ findings

common• Guidelines available for 10 yrs but imaging

procedures persist.• How many views?

- 5 views vs. 3. How much incremental benefit is gained by two additional views?

TC 3-30

By Cary Larson, It Came From the Far Side TC C-2

Medications

• Very commonly used in LBP• Analgesia• Role of NSAIDS• Muscle relaxants• Narcotic analgesics• Herbal remedies

Injection therapy

• Limited role in new onset LBP• Modest efficacy in the most optimistic studies• Substantial non-specific effect of any injection

Physical therapy

• Evaluation, advice, physical treatments• May include manual therapy• Minimal standardization• Little research in the past• Probably not helpful in the first several weeks

of acute LBP• May be useful in chronic LBP if the approach is

an active one

Spinal manipulation

• Commonly used across several specialties• Excellent patient satisfaction• Probably effective compared with no treatment• Probably not substantially different in clinical

outcome compared with usual allopathic treatment (evaluation, advice, meds)

• Somewhat more expensive

Acupuncture

• Biologic rationale unknown but substantial historical use

• Non-standardized intervention, substantial variability among practitioners, across theories

• Recent RCT negative when compared with medical treatment or massage

Early return to work• Work disability is a large portion of the social cost of

LBP• Pure educational programs are ineffective• Mounting evidence that active case management

stressing early return to work or modified work reduces cost and improves function

• Need to streamline process of modifying work• Early communication with a receptive supervisor is

key• Exercise is good

Utility of surgery

• Modest evidence for substantial improvement in leg pain in sciatica if not improved in 6 weeks of conservative rx

• Little consensus as to indications for and results from fusion for chronic LBP– Randomized trial demonstrated modest benefit in

disc surgery, degenerative spondylolisthesis

IDETIntradiscal electrothermal therapy

• Novel procedure, percutaneous• Heats disc to > 60 deg C• Several month rehab necessary• Case series data encouraging• European RCT of similar procedure negative• Urgent need for US RCT

PATIENT SATISFACTIONMD/HMO Chiropractor Patients Patients

How would (N=1027) (N=606)you rate… Percent answering “Excellent”

…the informationyou were given? 30.3 47.1…the way thedoctor treated yourback problem? 31.5 52.1…the overall resultsof your treatment? 26.5 42.1

(The P value for each question asked is P<0.0001)

TC 7-5

PATIENT SATISFACTION(Cont.)

MD/HMO Chiropractor Patients Patients

Did the doctor who (N=1027) (N=606)enrolled you in thisstudy… Percent answering “Yes”…take a detailed historyof your back pain? 68.4 88.4…do a careful examinationof your back? 79.9 96.1…explain the cause of yourback problem clearly 74.6 93.6

(The P value for each question asked is P<0.0001)

TC 7-6

Incidence of Chronic Low Back Pain Developing from Acute Low Back Pain

Of 100 patients presenting for acute low back pain:

7-8 will still have significant symptoms 3 months later

25 will have mild back pain but be able to perform their usual daily activities

TC 7-7

Where to refer?• Physical therapy can be very helpful, but how to

find the right one?- Exercise over modality

• Orthopedic/neurologic surgeons- Is an operation needed?

• PM+R• Multi-specialty pain management including

anesthesiology• Primary care with a hobby

- Kaiser-Permanente model

TC 6-30

Pain modulating therapy

• Tricyclic antidepressants– Dose titration

• (SSRI’s)• Possibly SNRI’s• Anti-seizure medication– Gabapentin, etc.

Chronic narcotic therapy

• Indicated in patients if not operative candidates• Limited RCT evidence shows analgesia but not

improved functional status• Requires clear understanding of duration and

conditions of renewal• Longer duration analgesics preferred– MS Contin– Methadone, etc.

Exercise

• Aerobic exercise• Exercise more important than any specific

maneuver• Dose (duration) matters• If possible, group reinforcement useful– Cognitive-behavioral therapy– Lay-led groups

Hayden, Ann Intern Med 2006

What interventions work?

• Surgery for selected patients in avoiding long-term leg pain after minimum of 6 weeks of symptoms

• Active physical therapies

- exercise

- education

• Receptive work environment

• Medications have only a modest role

• Early return to normal activities

TC 2-1

What Doesn’t Work-Most modalities provide only transient relief-Traction is not useful•Corsets only occasionally useful•Spinal fusion has a “success” rate of 50%•Epidural steroids, etc. of transient benefit•Spinal manipulation of unclear benefit in chronic LBP

TC 7-12

The physicians role

• Evaluation• Reassurance• Symptom relief• Encouragement of return to normal activity• Appropriate referral