1. Wallis, Laura


Moving away from accepted standards of care toward more questionable practices.


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Back pain is a major contributor to health care costs in the United States, accounting for about $86 billion in spending each year, and it's the fifth most common reason for visiting a physician-none of which will come as a surprise to most nurses. Most in the nursing profession are all too familiar with the aches and spasms of back and neck pain and the prevalence of chronic spinal complaints.

Figure. Phil Smith, ... - Click to enlarge in new windowFigure. Phil Smith, left, found relief from back pain without surgery after learning exercises from his physical therapist, Dan Babbel. Photo by Robert D. Tonsing.

What might be surprising, though, is that the management of back pain in recent years has worsened rather than improved, relying increasingly on care that veers away from accepted treatment standards and toward costly imaging, narcotics use, and surgical procedures. These were the findings of a study published in the September 23 JAMA Internal Medicine.


The current, well-established guidelines on back pain treatment-which stress conservative treatment, including the use of nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen and physical therapy-eschew the early use of imaging and other aggressive treatments. Mafi and colleagues hypothesized that given the additional guidelines released in the last decade, nonrecommended treatments would have decreased and recommended care would have increased. Their findings showed the opposite to be true.


The authors used nationally representative data on physician visits from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, from 1999 through 2010, and identified nearly 24,000 back pain-related visits, representing 440 million visits nationwide during the 12-year study.


Findings showed that the use of NSAIDs or acetaminophen decreased significantly-from 36.9% in 1999-2000 to 24.5% in 2009-2010-whereas narcotics use increased by nearly the same margin. At the same time, magnetic resonance imaging and computed tomography use increased from 7.2% to 11.3%, despite the fact that numerous trials have shown that imaging provides neither clinical nor psychological benefits to patients with "routine" back pain. And although the rate of referrals for physical therapy didn't change during the study period, referrals to other physicians rose from 6.8% to 14%.


"The 106% increase in referrals to other physicians is a previously unrecognized and important finding because such referrals likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations observed in other studies," the authors write.-Laura Wallis