In this issue of American Family Physician, Humphreys and colleagues1 review the role of neuroimaging in the evaluation of low back pain. They conclude that “since the majority of patients fully or partially recover within six weeks, imaging studies are generally not recommended in the first month of acute low back pain.”
This recommendation is consistent with the 1994 Agency for Health Care Policy and Research (AHCPR) clinical practice guideline for acute low back problems in adults.2 These evidence-based guidelines emphasize the identification of “red flags” in the patient history, the performance of a focused physical examination, and limited testing in most patients. Treatment emphasizes limiting bed rest, encouraging activity, and promoting functional outcomes.
Specific options for care include the use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and spinal manipulation. Newer evidence suggests that massage may play a short-term role in lessening symptoms and improving function. Surgery is recommended as an option in patients with radiculopathy who fail conservative therapy, and in select patients with conditions such as cauda equina syndrome, infection, tumor, fracture, or progressive neurologic deficit. Indeed, the majority of the evidence still suggests that in the care of patients with low back pain, less is more.3 So, what should the conscientious family physician offer patients with this common, painful, and occasionally disabling condition?
Keep Back Pain in Perspective
Almost all Americans experience low back problems at least once in their lifetime, and for many persons these difficulties are a recurring problem. Fortunately, few persons sustain protracted disability or prolonged pain, and many experts suggest that physicians should attempt to “demedicalize” back problems.4
Very few patients presenting with back pain have significant underlying problems warranting aggressive attention. A brief history and focused physical examination are usually sufficient to detect patients with a more serious problem. Thus, the clinician's goal is to promote relief from pain and promote functional recovery. As much as possible, family physicians must cope with the American penchant for fast action, hope for quick fixes, and love of technology. It is time that the medical community reframe low back pain as a part of life and a condition to be remedied with conservative therapy and medication rather than with a magnetic resonance image (MRI).
Use a Patient-Centered, Biopsychosocial Approach
In light of the evidence, it may be tempting to throw up our hands and abdicate all responsibility for low back pain. Yet, patients seek medical care for understandable reasons: they have difficulty performing normal activities, they are on a quest for the cause of their pain, they have a desire for specific therapies, and they need “validation of their suffering.”5 As physicians, we need to provide our patients with empathetic, understanding messages that are based on fact but are also responsive to the patient's underlying health beliefs and reasons for seeking care.3 There is good evidence suggesting that patients respond positively to education about low back pain, even when they are initially seeking an unwarranted intervention.6
We should understand our patients' expectations of care. For example, if the patient expects radiography, we can explain that “There is good evidence that patients like yourself are accurately diagnosed by a careful history and physical examination alone.” We can provide gentle education and tailored advice, and be alert for issues implicated in chronicity.
Quickly Identify Patients Who Are Failing to Recover
Most patients who fail to recover promptly (i.e., in four to six weeks) are at greater risk for developing long-term disability. Risk factors include having a compensation claim, job dissatisfaction, depression, substance abuse, and other psychosocial issues, but not the degree of initial pain, results of the physical examination, or defect on MRI. Physicians should routinely suggest follow-up for patients with low back pain, particularly those with such risk factors. If patients fail to recover as rapidly as expected, we should assess whether the patient's job is appropriate (given the person's age and physical condition) and offer goal-directed and functionally directed physical therapy. Family physicians can be important catalysts for their patients' recovery.
Comprehensively Treat Patients with Chronic Low Back Pain
Patients with chronic low back pain account for the majority of health care costs associated with low back pain. A recent review7 provides an evidence-based assessment of effective rehabilitative interventions in the care of patients with low back pain. Only therapeutic exercise had good trials demonstrating efficacy. While there is no cookbook approach to helping such patients, family physicians are ideally suited to mobilize the family, work-place, social service, and specialized rehabilitative resources to assist functional recovery. A simple and clear message to return to work can substantially improve outcomes.8
Improve Your Organization's Approach to Low Back Pain Management
Take a moment to reflect on your practice's approach to patients with low back problems. Perhaps you would like to reduce the number of unnecessary radiographs, develop a tool to quickly screen for “red flags” suggesting a more serious cause of the back problems, or partner with a local employer to develop a more proactive back-to-work program. Whatever your interest, focus on measurable outcomes in a few areas. Educate your office staff and your patients. Isn't it time to enhance your practice this way?