Doctors don’t follow back pain guidelines, study finds

Beautiful female backache, close up (Copyright 2008 Marija Savic. All rights reserved.)

A new study has found that many physicians are not following expert recommendations for the treatment of back pain. By not doing so, they are subjecting patients to unnecessary imaging tests, ineffective surgeries and unnecessary exposure to addictive narcotics, say the authors of the study published in JAMA Internal Medicine.

Several guidelines for back pain stress a more hands off approach, largely because more aggressive treatments have not been shown to improve the pain and subject patients to risks.

“One of the biggest things to realize is that when patients first present with back pain, the majority of them will have complete resolution of their symptoms within a couple of months,” said Dr. Bruce Landon, an author of the study and professor of health care policy at Harvard Medical School.

What works for back pain is time, and if needed, over the counter pain relievers like acetaminophen (Tylenol) and ibuprofen – along with staying active and physical therapy.

“They don't necessarily need expensive imaging tests such as MRIs, CT scans, and they don't need referrals to specialists,” he said. Studies have shown that these advanced imaging techniques do not lead to improvements in back pain.

The researchers compared data between two periods—1999 to 2000 and 2009 to 2010. They found that narcotic use increased from 19.3 percent to 29.1 during that time and use of the recommended over-the-counter pain relievers decreased from 36.9 to 24.5 percent.

“To me, the most worrisome findings were the rapid rise in narcotic prescriptions,” Landon said. Narcotics have not been shown to improve back pain, and they can lead to addiction. “In 2008, nearly 15,000 people died from narcotic prescription overdoses,” he added.

The study also found that the number of CT scans or MRIs increased from 7.2 percent to 11.3 percent during the study period, and the rate at which physicians referred patients to specialists, such as orthopedic surgeons, doubled from 7 to 14 percent. These referrals to specialists likely contributed to the rise in MRIs and the recent increase in back surgeries, the authors said, even though studies of lumbar fusion surgery have not shown an improvement in pain.

“I believe for the vast majority of patients with back pain, primary care physicians should be taking the lead on managing back pain,” Landon said. Part of the reason primary physicians refer is because patients demand to see specialists and to get high-tech screenings and pain killers.

“For the majority of cases, these things are not necessary, since the majority of back pain improves with time and minimal treatments,” he said.

Lastly, the study found that referrals to physical therapy remained unchanged at about 20 percent. Physical therapy such as stretching and core strength building, as well as regular exercise like walking, have been shown to improve back pain – particularly back pain that lasts more than a couple of months.

The best advice is to wait and see, Landon maintained. “I know it's hard to accept this in a society of instant solutions to our problems,” he said.