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Studies focus on diagnosis and treatment of low back pain, as well as related pain and disability

Low back pain often leads to disability and psychological distress. Individuals suffering from this problem are typically diagnosed with conventional x-ray of the lumbar spine. Magnetic resonance imaging (MRI)—either conventional or rapid MRI—may be used when the clinician suspects that the back pain stems from a serious condition, such as cancer or infection. Many people who suffer from low back pain seek complementary or alternative care from chiropractors, acupuncturists, or masseuses. Three recent studies supported by the Agency for Healthcare Research and Quality focus on the diagnosis and treatment of low back pain. The studies are summarized here.

Gray, D.T., Hollingworth, W., Blackmore, C.C., and others (2003, June). "Conventional radiography, rapid MR imaging, and conventional MR imaging for low back pain: Activity-based costs and reimbursement." (AHRQ grants HS09499 and HS11291). Radiology 227(3), pp. 669-680.

When evaluating low back pain, conventional x-rays are not sensitive enough to detect cancer, infection, or many degenerative causes of the pain, such as spinal stenosis. Conventional MRI is often used as an alternative to diagnose these problems, but it is costly and requires long imaging time. This study found that the time and costs for rapid MRI are roughly three times those for conventional x-ray (primarily due to the higher costs of acquiring and maintaining MRI equipment) but half those for conventional MRI.

The researchers randomized low back pain patients at each of four Seattle Lumbar Imaging Project (SLIP) sites to undergo conventional x-ray or rapid MRI of the lumbar spine. They compared imaging time and costs for these patients and for SLIP and non-SLIP patients undergoing conventional MRI as usual care in 2000, as well as Medicare reimbursements for imaging.

For 23 conventional x-rays, 27 rapid MRIs, and 38 conventional MRIs performed during 2000, all rapid MRI times exceeded those of conventional x-ray but were less than those of conventional MRI. Based on an activity-based analysis of equipment, radiologist, and technologist costs, average costs (in 2002 dollars) were $44 for conventional x-ray, $126 for 1.5-T rapid MRI, $128 for 0.3-0.35-T rapid MRI, $267 for 1.5-T conventional MRI, and $264 for 0.3-0.35-T conventional MRI. In 2002, Seattle-area Medicare fee schedule reimbursement for conventional x-ray was $44. Applying the ratio of reimbursement ($620) to costs ($264-$267) for conventional MRI to rapid MRI costs predicted reimbursement of $292 to $300 for rapid MRI. Thus, while current conventional x-rays costs exceed reimbursement, current conventional MRI and projected rapid MRI reimbursements exceed costs.

The researchers conclude that such cost estimates must be combined with data on clinical outcomes, functional status, and provider and patient satisfaction to more fully evaluate the proper role of rapid MRI in the initial evaluation of low back pain.

Cherkin, D.C., Sherman, K.J., Deyo, R.A., and Shekelle, P.G. (2003, June). "A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain." (AHRQ grant HS09989). Annals of Internal Medicine 138, pp. 898-906.

The limited effectiveness of conventional treatments for low back pain has prompted many dissatisfied patients to seek complementary and alternative medical (CAM) therapies such as massage therapy, spinal manipulation performed mostly by chiropractors, and acupuncture. These researchers reviewed systematic reviews and randomized controlled trials, published since 1995, to examine the evidence for the safety, effectiveness, and cost of these alternative therapies for low back pain.

The three studies that evaluated massage found this therapy to be effective for persistent back pain, especially for improving patient functioning. Recent studies evaluating acupuncture were of poor quality, so the reviewers were unable to assess the effectiveness of this therapy. The preponderance of evidence from 26 trials evaluating spinal manipulation (including chiropractic manipulation) for back pain indicate that this treatment has real but modest benefits for both acute and chronic low back pain.

All of these treatments seem to be relatively safe. Serious problems are rare and generally not life-threatening. Because costs have rarely been measured in trials of CAM therapies, little is know about the cost-effectiveness of these treatments for back pain. Data from one trial suggest that the initial costs of a course of massage therapy may be justified by the substantial improvements in functional outcomes and reduced use of health care services for back pain during the year after treatment. The modest benefits of spinal manipulation and questionable benefits of acupuncture were not associated with any future cost savings. The authors caution that trials of CAM therapies for back pain are complicated by the common use of various techniques; adjuncts to these techniques, for example, herbs for acupuncture, aromatherapy for massage, and ultrasound for manipulation; and lifestyle recommendations.

Hurwitz, E.L., Morgenstern, H., and Yu, F. (2003). "Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA low-back pain study." (AHRQ grant HS07755). Journal of Clinical Epidemiology 56, pp. 463-471.

Many studies have found an association between low back pain and depression and other types of psychological distress. However, this is the first longitudinal study of primary care low back pain patients to show the interrelationship between low back pain and disability and subsequent psychological distress. The investigators followed 681 primary care patients with low back pain for 18 months. They assessed patients' pain, disability, and psychological distress at 6 weeks and at 6, 12, and 18 months.

Results showed that current pain and disability increased by 36 percent and 23 percent, respectively, the likelihood of subsequent psychological distress, and that current psychological distress greatly increased the likelihood of subsequent pain and disability. Patients with clinically significant or frequent pain or disability were 5 to 10 times more likely to have appreciable pain or disability at the subsequent followup assessment, after controlling for psychological distress at the previous assessment. Similarly, psychologically distressed patients were more likely than less distressed patients to be distressed at the subsequent followup assessment, after controlling for each previous low back pain or disability variable.

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