Back Pain Treatment Often Not In Line With Guidelines

Exercise Eases Low Back Pain

“This is kind of concerning,” said Dr. Steven Cohen, an anesthesiologist and critical care doctor at the Johns Hopkins School of Medicine in Baltimore who didn’t participate in the research. Surgery, injections and scans for back pain “have all gone up pretty dramatically,” he told Reuters Health. “We have increased utilization, yet we don’t have better treatment outcomes.” The American College of Physicians and the American Pain Society recommend that people with low back pain consider treatment with Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs), as well as heating pads and exercise. The groups say doctors should only order CT and other scans when they suspect nerve damage. Opioids are only recommended for patients with “severe, disabling pain” that doesn’t get better with over-the-counter medicines – and their risks, such as for abuse and addiction, should be weighed against potential benefits. For the new study, Dr. Bruce Landon from the Harvard Medical School in Boston and his colleagues tracked nationally-representative data on outpatient visits for back and neck pain collected between 1999 and 2010. The researchers had information on about 24,000 visits, which represented a total of 440 million appointments across the U.S. During that span, they found the proportion of patients prescribed Tylenol and NSAIDs dropped from 37 percent to 25 percent. At the same time, the proportion given narcotics rose from 19 percent to 29 percent. About 11 percent of people with back pain had a CT or MRI scan in 2009 and 2010, compared to seven percent in 1999 and 2000. Finally, although the rate of referrals to physical therapy held steady during the study period, the proportion of patients referred to another doctor – likely for surgery or other treatments – doubled from seven to 14 percent, the researchers reported Monday in JAMA Internal Medicine.
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They found that in people who were normal weight, defined as a body mass index of 20 to 25, the risk of low back pain was 2.9%. (A 5′ 10″ person who weighs 174 lbs has a BMI of 25.) In those who were overweight (BMI of 26 to 30), low back pain risk was 5.2%. In the obese, a BMI of 31 to 35, the risk grew to 7.7%. And in the morbidly obese, a BMI of 36 or more, the risk was 11.6%. (A 5′ 10″ person weighing 251 lbs has a BMI of 36.) “We showed both increased BMI and inactivity were independent risk of low back pain,” said Smuck. “Perhaps the best news out of this study is that big gains can be made by making some incredibly modest changes in activity.” The researchers found different ways to achieve the improvements: The typical overweight person increasing their amount of moderate activity such as brisk walking, riding a bike, or general gardening by less than 20 minutes a day can reduce back pain risk by 32%. For people with BMIs of 36 or more, the average duration of time spent during a bout of moderate activity was 1.3 minutes. However, by increasing that time by 1 minute, the risk of back pain dropped by 38%. For years, anecdotal evidence has led spine specialists to tell overweight people to lose weight and exercise; now there is hard data to back up those beliefs, said Michael Reed, a physical therapist and spine specialist with the Hospital for Special Surgery in Jupiter, Fla. One question the study could not answer, however, is why obesity increases the risk of low back pain.
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Back Pain? Choose Wisely!

4. Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic or cervical spine pain. 5. Don’t recommend bed rest for more than 48 hours when treating low back pain. To create this list, NASS appointed a multidisciplinary task force to identify five areas in which to make recommendations. Based on the scientific evidence, existing clinical practice recommendations and expert opinion, the task force collaboratively drafted a list of nine recommendations which was subsequently submitted to the NASS Board of Directors for review and ranking. After further refinement, the final list was approved by the NASS Board of Directors. “The North American Spine Society has shown tremendous leadership by releasing its list of tests and procedures that may be commonly performed in spine care, but aren’t always necessary,” said Richard J. Baron, MD, president and CEO of the ABIM Foundation.
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