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Researchers examine treatment and outcomes for low back pain

Although a majority of patients with acute low back pain use self-care strategies without seeing a health care professional, 37 percent may see one or more of a variety of providers, including a primary care physician, chiropractor, orthopedic or neurologic surgeon, and/or a physical therapist. The North Carolina Back Pain Project, led by Timothy S. Carey, M.D., M.P.H., of the University of North Carolina at Chapel Hill and supported by the Agency for Health Care Policy and Research (HS06664 and HS09370), examines variations in and effectiveness of diagnosis and treatment of low back pain.

Three recently published articles by Dr. Carey and his colleagues are summarized here. They suggest that once experienced, low back pain becomes a part of life for almost half of those affected, and for many, it is intermittently disabling. Repeated visits and procedures do not appear to improve patients' long-term well-being, but they clearly account for substantial health care costs. Finally, back pain prognosis does not differ based on the type of provider initially seen or the level of practitioner confidence.

Carey, T.S., Garrett, J.M., Jackman, A., and Hadler, N. (1999). "Recurrence and care seeking after acute back pain: Results of a long-term follow-up study." Medical Care 37(2), pp. 157-164.

This study found that adults seeing different types of providers for acute back pain had similar back pain recurrence rates and functional status during recovery. This was true despite very different philosophies of care and practice patterns among primary care physicians (PCPs), chiropractors, orthopedic surgeons, and health maintenance organization PCPs. However, patients who had originally sought care from a chiropractor were two to three times more likely to seek care for modest recurrences of low back pain. Although chiropractic care was associated with excellent patient satisfaction, it did not improve functional status, and therefore, it was somewhat more expensive, according to the researchers.

Based on periodic interviews with 921 patients from their initial back pain visit until 22 months later, the researchers found that back pain recurred in over half of patients seen for low back pain. Yet despite recurrences, almost all of these patients were reasonably functional, and work disability was rare. The likelihood of any recurrence of back pain increased with the number of back pain episodes experienced prior to the current episode of pain. For instance, 15 percent of those with no previous episodes had a severe recurrence compared with 35 percent of those with more than five lifetime episodes of low back pain.

The role of the health care system in caring for these patients remains problematic. Repeated visits, with or without multiple radiographs and procedures, did not discernibly improve patients' long-term well-being but clearly resulted in substantial health care costs. Yet patients continued to seek care, looking for reassurance and relief from their symptoms. One option would be to de-medicalize the experience, note the researchers. This would require reversing practitioner and patient expectations so that back pain recurrences might be considered a part of life similar to recurrences of disabling upper respiratory infections in young individuals.

Meanwhile, researchers and providers should concentrate on finding ways to improve functional status for the small number of very high-cost back-pain sufferers. Since current treatments only marginally affect their state, the emphasis should be placed on low-cost treatment and return to functioning, rather than complete symptom relief. This may afford them the greatest opportunity for improvement, conclude the researchers.

Sundararajan, V., Konrad, T.R., Garrett, J., and Carey, T. (1998, August). "Patterns and determinants of multiple provider use in patients with acute low back pain." Journal of General Internal Medicine 13, pp. 528-533.

Although 79 percent of back pain patients see only the initial physician who began their care for low back pain, a substantial minority (21 percent) see multiple providers, which is an expensive venture. The average cost of seeing only the initial provider is $439 compared with $1,137 for multiple providers, according to this study. The researchers prospectively studied patients with acute low back pain after an initial visit to a private primary care physician (PCP), chiropractor, orthopedic surgeon, or HMO PCP and interviewed them periodically until they recovered completely or to 6 months.

Duration of pain prior to the initial visit, sciatica, higher disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and type of initial provider were significantly associated with seeking care from multiple provider types. Age, race, sex, and education were not significant. About 14 percent of those initially seeing a private PCP saw multiple providers, compared with 19 percent of those initially seeing a chiropractor, 30 percent of patients seeing an orthopedic surgeon, and 9 percent of those seeing an HMO PCP.

Although only 12 percent of those who had recovered by 3 months saw multiple provider types, 54 percent of those who had not recovered by then did so. Seeking further care may be an appropriate response to lack of improvement, suggest the researchers. They conclude that the correlation of patient-initiated use of multiple provider types with lack of symptomatic improvement reflects the inability of physicians to offer these patients an effective way to manage their low back pain, especially as it becomes chronic.

Smucker, D.R., Konrad, T.R., Curtis, P., and Carey, T.S. (1998). "Practitioner self-confidence and patient outcomes in acute low back pain." Archives of Family Medicine 7, pp. 223-228.

Chiropractors clearly are more confident than physicians in their ability to treat low back pain, and their patients typically are more satisfied. But receiving care from a more confident practitioner does not lead to faster recovery or more patient satisfaction, according to this study. Patients seen by PCPs with stronger self-confidence scores did not recover faster than patients of physicians with weaker scores. They had similar time to improved function and pain resolution. Thus, bolstering practitioner confidence in diagnostic or therapeutic maneuvers for acute low back pain is unlikely to benefit most primary care patients seen for this problem, conclude the researchers.

They surveyed 189 physicians and chiropractors who participated in the North Carolina Back Pain Project. The survey contained 10 items that measured aspects of practitioner confidence and attitudes in assessing and treating patients with low back pain. Patients were interviewed by telephone after their initial visit to the practitioner and periodically up to 6 months or complete recovery, whichever came first.

Chiropractors had significantly stronger self-confidence scores than physicians, but level of practitioner confidence did not predict patient outcomes. The researchers suggest that other psychosocial factors in the physician-patient encounter, which were not measured in this study, may affect outcomes, particularly for patients with chronic pain syndromes. These may include the physician's communication skills, emotional support provided to the patient, amount of time spent with the patient, and hands-on evaluation and treatment.

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