Daniel DeNoon

Back pain often overdiagnosed and overtreated

What doctors call “routine” back pain can really, really hurt. Surprisingly, the best treatment is usually quite conservative—over-the-counter pain relievers, ice and heat, and gentle exercise. Yet for decades, many doctors have been ordering more and more unnecessary tests, narcotics, and referrals to surgery.

“Most routine back pain will improve on its own with conservative therapy in three months, often shorter than that,” says Dr. Bruce E. Landon, professor of health care policy at Harvard Medical School. “Even more importantly, when we do more aggressive things—such as injections, imaging, and surgery—the long-term outcomes don’t change at all. These things have very little impact on what is going on, and they have the potential to make things worse.”

The trend of overdiagnosis and overtreatment is getting worse, according to a new study by Landon and his colleagues. They analyzed nationally representative data from 1999 through 2010 on nearly 24,000 outpatient visits for acute, new onset or chronic flare-up back pain to see if these people were treated according to established, evidence-based guidelines. Endorsed by both U.S. and international experts, these guidelines:

  • call for treatment with non-steroidal anti-inflammatory drugs (NSAIDS, such as ibuprofen and naproxen) or acetaminophen (Tylenol and generic).
  • call for referral to physical therapy when appropriate.
  • advise against early referral for imaging (such as MRI and CT scans) except in rare cases where “red flags” suggest something other than routine back pain.
  • advise against prescribing narcotics.
  • advise against early referral to other physicians for injections or surgery.

Back pain guidelines ignored

The study, published in the journal JAMA Internal Medicine, revealed that doctors were increasingly ignoring these guidelines. During the study period:

  • use of NSAIDS and acetaminophen went down, from 36.9% of visits in 1999-2000 to 24.5% of visits in 2009-2010.
  • prescriptions for narcotic pain relievers went up, from 19.3% of visits in 1999-2000 to 29.1% of visits in 2009-2010.
  • referrals to physical therapy remained low at 20% of visits.
  • referral to other physicians went up, from 6.8% of visits in 1999-2000 to 14% of visits in 2009-2010.
  • referrals for CT or MRI scans increased from 7.2% of visits in 1999-2000 to 11.3% of visits in 2009-2010.

“It is hard to not do anything aggressive, especially when you are having a lot of pain,” Dr. Landon says. “So people ask for these more advanced things and, unfortunately, doctors are often willing to prescribe them because that is the path of least resistance.”

This path of least resistance for primary care providers is a treasure trove for surgeons, specialists, and pain clinics. In the United States, health care for back pain adds up to about $86 billion each year. When people with routine back pain are referred for MRI imaging, they are eight times more likely to have surgery.

When people with back pain ask for off-guideline treatments, it takes time to understand their expectations and to explain how conservative treatment is better suited to their situation. Doctors may not feel they have that kind of time, notes Dr. John Mafi, chief medical resident at Harvard-affiliated Beth Israel Deaconess Medical Center and first author of the study.

“It is hard to reason with people when they are in a lot of pain,” he says. “I am in favor of the honesty route. I tell people with first-time back pain that narcotics don’t necessarily help and, frankly, they are a risk. Instead of reaching for the narcotics, I suggest that if they start with the acetaminophen or ibuprofen and get rest and use ice, the vast majority of the time this will get better on its own.”

Dr. Landon notes that it takes five or 10 minutes to explain things as Dr. Mafi suggests, but it takes only 10 seconds to order a test or write a prescription.

“The way our health care system is set up right now makes it hard to do the right thing,” Dr. Landon says. “Orthopedic surgeons, neurosurgeons, and pain medicine doctors get paid for doing things, not for counseling.”

What to do for low back pain

If you have a first-time bout with low back pain, or are in the midst of another go-round with it, here’s what Dr. Jeffrey N. Katz, professor of medicine and orthopedic surgery at Harvard Medical School, recommends in Low Back Pain, a Special Health Report from Harvard Medical School.

  • Cold and heat. At the beginning of the flare-up, start with ice or cold packs. After 48 hours, switch to gentle heat.
  • Rest. If you are in severe pain when sitting or standing, bed rest can be helpful. But limit it to a few hours at a time, for no more than a couple days.
  • Exercise. An exercise program can help the healing process during an acute flare-up, prevent repeat episodes of back pain, and improve function if you have chronic low back pain. Work with your doctor or physical therapist to develop a suitable exercise plan.
  • Medication. Over-the-counter pain relievers, such as acetaminophen or an NSAID like aspirin, ibuprofen, or naproxen, are usually all that is needed to relieve acute low back pain. They work best when taken on a regular schedule, rather than after the pain flares up.

If these strategies don’t work, talk with your doctor about more advanced options for treating low back pain.

Comments:

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  2. Rich

    Great article. I have been living with back pain for many years now. I do all of the above mentioned. I ice it, I rest it, I do everything. There was still pain. But I tried this inversion table and it works so well! It has helped me a lot.

  3. Corona

    I have serious back pain after an accident for almost five years now. Used to refuse pain killers but it is otherwise impossible to function is one way or another. Orthomanual therapy helps for me as well to finally become painless for some time once in a while. However, I have several accidents due to difficult motorical issues so painless only last for a couple of weeks. When I fall, the back pain is back again most of the times. Any idea how to train to avoid that…

  4. Camilla Watts

    Interesting article! In this article, you will learn all about back pain and how to relieve it. But for me, I suggest a stretching device called the Backtrax(R). This will helped you gain relief without surgery or meds. I think if you want back pain relief without surgery or meds, this is the best alternative. They also have an unconditional money back guarantee, so there’s nothing to lose.

  5. Tina Wise

    The problem surfaces when Doctors order unnecessary drugs or even do surgery when not even necessary but just to gain profits. The tips you gave are already enough to ease chronic back pains.

  6. ellysecoyte

    It is noteworthy to mention that the National Institute for Health and Care Excellence (NICE) low back pain early management clinical guidelines advocate not only exercise as one means of physical therapy.

    I have had back pain for over 1 years. Now i am using pain Relief medicine

  7. mebel jepara

    It is noteworthy to mention that the National Institute for Health and Care Excellence (NICE) low back pain early management clinical guidelines advocate not only exercise as one means of physical therapy, but also spinal manipulation and acupuncture:
    mebel jati

  8. Sangeeta

    That’s a good post. Back pain is a common problem that affects most people at some point in their life.

  9. Nita Frazier

    This study is in reference to “ROUTINE” backpain which is usually due to a sprain or “overwork”; not spinal disease. As far as the routine backpain treatment I agree. However, the news media coverage and JAMA article to not make the difference clear. I was first diagnosised with advance lumbar and cervical spinal arthritis at 33 and multi spinal region/multi disc level disease at 35. I was completely disabled at 48. An MRI or CT is the only current means of differentiating between a disease vs. routine back pain. An initial MRI is necessary for the provider and patient to know what the cause of the pain is, proper course of treatment, and prognoss. Spondylosis patients need a different course of treatment then a sprain.

  10. Brian

    I have had a hip problem since 11, and most of my life have suffered various back pain due to the hip. Mostly i have phsyio and exercise regularly, but at times need drugs and stuff that just do not seem to help. Recently my wife put me onto a natural collagen supplement which is meant for skin care and anti aging, but surprisingly i have had no hip pain, little to no back pain due to this collagen supplement. So wondering whether alot of pain is due to lack of protein and vitamins that the body lacks due to diet and nutrition?

  11. Dr. Sewell AP

    As an acupuncture physician in private practice in Sarasota. I treat back pain patients on a daily basis. By the time most clients reach my clinic they are desperate for relief. Electro-acupuncture, low level laser therapy and point injection therapy have all proved effect in helping to reduce pain. I encourage all patients to explore the options that exist. Drugs and surgery are not the only answers.

    • Sally Henderson

      You’re quite right! My husband threw out his back at work. It was horrible. Fortunately we found a talented acupuncturist and Jim was able to get back to work. Acupuncture works. We’re believers.

  12. Chato Stewart

    I don’t think “Back pain often overdiagnosed” – If you have pain in your back it’s a fact. the type of pain may be where or where the cause of the pain is from may be at question. Not the pain. How to handle it is out of control – that i’ll give you. :)

  13. Ty

    I have had lower back pain for over 20years and have never had to resort to narcotics or injections. Physical therapy,correct posture (while sitting or standing)and must importantly the right furniture i.e chair, mattress goes a long way in ensuring long periods free of back pain.

  14. Ecks Why Zed

    Obviously guidelines set by people who have never had crippling back pain. People don’t want to struggle with agony and severely limited activity for months waiting for “nature to take its course”. I’m sure bosses will be understanding and happy to give us a couple of months off to heal (not).

    Take a combo of Endone, Panadol Osteo and Celebrex and then get the injections and you can start living again. Long term outcomes are not to only thing – we need to get people back into life so they are capable of exercise of core muscles.

  15. Walbus

    I always (when I feel a pain in my back), heating in plenty of bedding and the next day I did not feel anything uncomfortable, nice article, greetings from walbus :)

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