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06-10-2013 | Pain medicine | Article

Management of back pain ‘poor and worsening’


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medwireNews: A study of how back pain is managed in the USA has uncovered an array of poor practice, including the overuse of unproven therapies and underuse of evidence-based interventions.

The survey, which also found high rates of inappropriate diagnostic imaging and referrals to other physicians, suggests that better management of spinal disease could benefit the healthcare system, say the authors.

“With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care,” write Bruce Landon (Harvard Medical School, Boston, Massachusetts, USA) and co-authors in JAMA Internal Medicine.

The team used data from two national surveys on 23,918 outpatient visits for back or neck pain to characterize the treatment of back pain between 1999 and 2010.

The number of visits for back pain rose over the study period, as did the mean age of patients and proportion of visits from Medicare patients. There was also a decrease in the proportion of patients with acute or new-onset back pain and an increase in the proportion with long-term symptoms.

With regard to management, use of NSAIDs or acetaminophen decreased from 36.9% to 24.5% while use of narcotics – which have no proven efficacy in back pain – rose from 19.3% to 29.1% and use of muscle relaxants and benzodiazepines rose from 19.6% to 23.7%. Use of neuropathic agents more than doubled, from 3.4% to 7.9%.

Referrals to physical therapy were unchanged, at approximately 20.0% across the study period, whereas referrals to other physicians increased from 6.8% to 14.0%. There was no change in the use of plain X-rays, at approximately 17.0%, but use of magnetic resonance imaging and computed tomography scans increased from 7.2% to 11.3%.

The team notes that the 106% relative increase in referrals to other physicians is “previously unrecognized” and important because such referrals “likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations.”

With regard to the increase in advanced diagnostic imaging, Landon et al note that such imaging has been repeatedly found to provide neither clinical nor psychologic benefits; rather, it exposes patients to ionizing radiation and is a strong predictor of subsequent spinal surgery.

They conclude that the management of back pain is “worsening”, and summarize: “Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines.”

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Joanna Lyford, Senior medwireNews Reporter