Seven Sins of Back Pain Diagnosis
Biloine W. Young • Wed, August 14th, 2013
Oh, my aching back! Doctors frequently hear that lament from patients who have no medical reason for their discomfort, such as a spinal injury or an accident. According to a study by researchers at Boston’s Beth Israel Deaconess Medical Center, too many physicians give these patients unnecessary imaging tests or treat them with surgeries that do not help their pain.
In the study, reported by Deborah Kotz of Boston.com, researchers looked at over 24,000 medical records from patients who were treated for back problems beginning in 1999 and running through 2010. They found an increase in referrals for surgeries and in prescriptions written for addictive narcotics for pain. They also found that fewer patients were getting over-the-counter pain relievers such as ibuprofen or acetaminophen, which guidelines recommend as a first-line treatment.
The U.S. Food and Drug Administration (FDA) has advised against the use of opiates for the treatment of low back pain because of the risks of developing an addiction or dying from an overdose. It warns that chronic use of anti-inflammatory drugs can increase the risk of ulcers and gastrointestinal bleeding.
“The first step in addressing a problem is to admit that you have it, and [this study] forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain,” Donald Casey, M.D. of the New York University Langone Medical Center, wrote in an editorial that accompanied the study.
The study author, John Mafi, M.D. told Kotz, “Patient expectations probably play a big role as well as financial incentives for doctors. It takes longer to sit and reassure patients that their pain will likely resolve on its own than it does to order an MRI.”
The study authors listed seven common mistakes doctors make when faced with a patient suffering from low back pain.
- Failing to correctly categorize back pain by its cause. Doctors must be sure to conduct a physical examination to find a cause, if possible, such as spinal stenosis.
- Ordering an imaging test to make a diagnosis. Doctors should not order an MRI or CT scan unless a patient has tingling in the legs—a sign of a nerve problem such as spinal stenosis—or a previous history of cancer. Such tests are warranted, they wrote, only when the physical exam points to a serious underlying condition and only if surgery or other invasive treatments may be options to treat it.
- Blaming the pain on bulging disks. Often these imaging tests reveal disk problems, but studies have shown that the majority of people develop abnormalities in their spinal disks as they age, often without having any pain from them.
- Forgetting to tell patients that back pain usually resolves regardless of how it’s treated.
- Overprescribing narcotics. The study found that the percentage of medical visits that resulted in a prescription for opiates like oxycodone or hydrocodone increased from 19% to 29% over the course of the study while those advised to take over-the-counter acetaminophen or anti-inflammatory drugs like ibuprofen decreased from 37% to 25%.
- Underemphasizing exercise. Many doctors think that physical activity makes low back pain worse when it often helps the body heal faster. “Advise patients to remain active,” the guidelines state.
- Neglecting to refer patients for complementary treatments. Physical therapy, acupuncture, massage therapy, and spinal manipulation can all be tried if low back pain fails to resolve on its own. Evidence from clinical trials on these therapies is not robust, according to the guidelines. However, these treatments have fewer risks than surgery or chronic use of pain killers.