Who's in Charge of Treating the Back Pain Patient? The Doctor or the Patient?
In the last 30 years, as the Baby Boomers became adults, the management of low back pain (LBP) has changed. Baby Boomers were born between 1946 and 1964. Parents of Baby Boomers were more likely to expect the doctor to make all the decisions. But patients today are active consumers. This has resulted in a new concept of patient care called shared decision-making.
In this article, spine surgeons get together and discuss this new idea. They also review a separate issue of wide regional variations in patient care. Surgical care especially seems to have large differences in how low back pain is treated from one area of the country to another. In other words, patients with the same type of problem may be treated one way in one geographical location and receive different care elsewhere.
Today's focus on evidence-based medicine is helping sort out whether this variation problem occurs as a result of physicians' lack of awareness of up-to-date treatment guidelines or if it is due to a lack of physicians in a geographical area. This outcomes movement is expected to help provide the evidence needed to make medical and/or surgical decisions about care for low back pain.
As part of the evidence-based and outcomes movement, we have new research information about low back pain. We've always known the number of people affected by back pain on any given day of the year is pretty high. This is referred to as point prevalence. But the pain doesn't last and symptoms usually go away within the first couple of days-to-weeks.
This progression of symptoms and symptom resolution is referred to as the natural history.
Knowing the natural history of acute low back pain helps physicians feel confident in prescribing limited bed rest (one to two days max), short-term use of analgesics (pain relievers), and Physical Therapy or chiropractic care.
More advanced test procedures can be ordered when pain does not improve with this management approach. For example, constant and severe pain may be an indication of something more serious such as a tumor or infection. The results of the X-rays determine the next step. This could be referral to another specialist. Or it may be persistence in getting the individual better with a continued program of conservative (nonoperative) care.
Physicians now have an algorithm to follow regarding further testing procedures with MRIs and other more advanced imaging. An algorithm is the step-by-step decision-making process used by health-care professionals. It relies on a flow of: if this happens, then that should be our next step.
In this paternalistic model, the physician is still determining when to order X-rays or MRIs and when to refer to another health care professional. Exercise, manual therapy, behavioral therapy, or functional activities programs are just a few of the conservative care options.
The authors report no new information about more invasive treatments (e.g., lumbar disc injections, intradiscal electrothermal treatment). There are no new breakthroughs in lumbar spine surgery (e.g., fusion, disc replacement). Disc replacement preserves spinal motion but the procedure costs more and the final outcomes aren't better than with fusion. Fusion is considered a last resort after failure of nonoperative care.
And after looking over all the studies and comparing current practice, the authors say it looks like physician factors (rather than a lack of evidence) does indeed account for the wide regional differences in the way low back pain is treated.
Patients should be made aware that the recommended plan of care (POC) for chronic low back pain is as follows:
Patients who know what the recommended guidelines are (based on current research evidence) in a good position to help make treatment decisions for themselves. Today's health care system can allow for shared decisions and a plan directed by the consumer.
Bradley K. Weiner, MD, and Andrew Jason Schoenfeld, MD. Applying Shared Decision Making to Low Back Pain. In The Journal of Musculoskeletal Medicine. September 2008. Vol. 25. No. 9. Pp. 421-427.