Many patients who don’t have a medical reason for their back pain -- like a spine injury from a car accident -- get unnecessary imaging tests and treatment with surgeries that won’t do much to ease their discomfort. That’s because doctors still aren’t following practice guidelines that have been around for 20 years. In fact, this problem seems to be getting worse, according to a new study from Beth Israel Deaconess Medical Center.
When the researchers reviewed 24,000 medical records from patients treated for back problems during 1999 through 2010, they found an increase in referral for surgeries and an increase in prescriptions being written for addictive narcotics to reduce pain.
At the same time, fewer patients are getting over-the-counter pain relievers like ibuprofen or acetaminophen, which the guidelines recommend as a first-line treatment.
“The first step in addressing a problem is to admit that you have it, and [this study] forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain,†said Dr. Donald Casey, a general practitioner at New York University Langone Medical Center in an editorial that accompanied the study.
But researchers still don’t know why doctors ignore recommendations that are based on studies that show which treatments work.
“Patient expectations probably play a big role as well as financial incentives for doctors to order expensive imaging tests,†said study author Dr. John Mafi. Also, he added, “it takes longer to sit and reassure patients that their pain will likely resolve on its own than it does to order an MRI.â€
Learning about the seven common mistakes doctors make when it comes to treating low back pain -- and what the right course of action should be -- might help you avoid unnecessary tests and overtreatment.
1. Failing to correctly categorize back pain by its cause. Doctors sometimes neglect to ask the right questions or perform the proper physical exam to determine whether a patient has “non-specific†low back pain or pain that’s due to a narrowing of the spinal canal called spinal stenosis or another specific cause like a fracture.
2. Ordering an imaging test to make a diagnosis. Doctors shouldn’t immediately order an MRI or CT scan to determine the cause of back pain if a patient doesn’t have any red flags like tingling in the legs -- a sign of a nerve problem like spinal stenosis -- or a previous history of cancer. Such tests are warranted only when the physical exam points to a serious underlying condition, the guidelines state, and only if surgery or other invasive treatments may be options to treat it.
3. Blaming the pain on bulging disks. This stems from ordering too many imaging tests for nonspecified back pain. Often these imaging tests reveal disk problems, but studies have shown that the majority of people develop abnormalities in their spinal disks as they age, often without having any pain from them.
4. Forgetting to tell patients that back pain usually resolves regardless of how it’s treated. “In the 1990’s, doctors were criticized for ignoring patient’s pain, and there was a big push to emphasize pain management, but we’ve gone a little too far,†Mafi said. Sometimes, patients need to understand that there’s no quick fix for back pain, but that the body often needs a few weeks to heal whatever injury or muscle strain that triggered it.
5. Overprescribing narcotics. The new study found that the percentage of medical visits that resulted in a prescription for opiates like oxycodone or hydrocodone increased from 19 percent to 29 percent while those advised to take over-the-counter acetaminophen or anti-inflammatory drugs like ibuprofen decreased from 37 percent to 25 percent.
The guidelines recommend over-the-counter pain relievers if needed and don’t mention the use of narcotics; the US Food and Drug Administration has advised against the use of opiatics for the treatment of low back pain because of the risks of developing an addiction or dying from an overdose. Chronic use of anti-inflammatory drugs can increase the risk of ulcers and gastrointestinal bleeding, which patients also need to discuss with their doctors.
6. Underemphasizing exercise. Many doctors mistakenly think that physical activity makes low back pain worse when it often helps the body heal faster. “Advise patients to remain active,†the guidelines state.
7. Neglecting to refer patients for complementary treatments. Physical therapy, acupuncture, massage therapy, and spinal manipulation can all be tried if low back pain fails to resolve on its own. There’s some evidence that such therapies can help relieve pain, though evidence from clinical trials isn’t robust, according to the guidelines. These treatments do, though, have fewer risks than surgery or chronic use of pain killers.
Deborah Kotz can be reached at dkotz@globe.com. Follow her on Twitter @debkotz2.
