Many patients who don’t have a medical reason for their back pain — such as a spine injury from a car accident — get unnecessary imaging tests and 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 study from Beth Israel Deaconess Medical Center.
When the researchers reviewed 24,000 medical records from patients treated for back problems from 1999 through 2010, they found an increase in referrals for operations and an increase in prescriptions being written for addictive narcotics to reduce pain, according to the study published last Monday in the journal JAMA Internal Medicine.
At the same time, fewer patients are getting over-the-counter pain relievers such as ibuprofen or acetaminophen, which the guidelines recommend as a first-line treatment.
Researchers don’t know why doctors ignore the recommendations from the American Pain Society and American College of Physicians, which 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.”
Learning about seven common mistakes doctors make when 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 caused by a narrowing of the spinal canal called spinal stenosis, or another specific cause such as 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 such as tingling in the legs — a sign of a nerve problem such as 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 tests reveal disk problems, but studies have shown that the majority of people develop abnormalities in their spinal disks as they age, often without pain.
4. Forgetting to tell patients that back pain usually resolves regardless of how it’s treated. “In the 1990s, 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 triggered it.
5. Overprescribing narcotics. The new study found that the percentage of medical visits that resulted in a prescription for opiates such as oxycodone or hydrocodone increased from 19 percent to 29 percent, while visits resulting in advice to take over-the-counter acetaminophen or anti-inflammatory drugs such as ibuprofen decreased from 37 percent to 25 percent. The guidelines say narcotic drugs should only be used “judiciously in patients with acute or chronic low back pain who have severe, disabling pain that is not controlled” with other medications, citing “substantial risks” of drug abuse and addiction. They also note that chronic use of anti-inflammatory drugs can increase the risk of ulcers and gastrointestinal bleeding.
6. Underemphasizing exercise. Many doctors 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, supervised exercise programs, and spinal manipulation can all be “moderately effective” treatments for low back pain that doesn’t resolve, according to the guidelines. They may not do much, however, to help more serious conditions such as spinal stenosis.
Deborah Kotz can be reached at firstname.lastname@example.org.