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Clinical Practices in Low Back Pain Management

The purpose of this study was to assess both how health care providers manage new onset uncomplicated low back pain (LBP) in Worker's Compensation cases and to determine which methods increase costs. 98 LBP subjects and their treatment courses were evaluated for one year. Subjects did not have a pre-existing history of LBP or any concurrent injuries or conditions.

The following table summarizes the methods practitioners commonly use to manage LBP:

Methods

Percentage

X-ray

65%

MRI

22%

At least one Prescription

90%

Muscle Relaxants

66%

Other NSAIDS

61%

Ibuprofen

39%

Opioids

38%

Modified Work Duty

90%

Back Exercises

47%

Bed Rest

29%

Referred for Physical Therapy

62%

 

The authors conclude these findings suggest overuse of diagnostic and treatment modalities. The authors claim diagnostic imaging was overused in terms of the total number, and also the time frame in which the x-rays and MRI's were performed:

"While plain films are not recommended within the first month of clinical management except under certain circumstances, over half of the patients in the sample were x-rayed within the first month, and 38% were ex-rayed during their first clinic visit...Such over-utilization of diagnostic test represents a clear cost inefficiency and, in the case of plain films, a potentially unnecessary exposure to ionizing radiation for the patient."

Over-prescribing expensive or habit forming medications was also of concern. The authors were surprised at the high rate of opioid analgesic prescribing—considering the uncomplicated nature of the cases at hand. All 38% of the opioid-users renewed their prescription, and the authors claim, "this duration far exceeds the recommendations of the guidelines and, it is suggested, would increase disability duration in may cases."
In summary, the authors suggest that inappropriate medical treatment may actually worsen recovery rates:

"It is of particular note that the cases were specifically selected for their clinically uncomplicated nature. As best as could be determined, the patients in this sample had no prior history of LBP and had no concurrent injuries or medical conditions that could impact clinical management. In addition, these cases were not in any way suspicious for the presence of fracture, tumor, infection, or cauda equina syndrome,, nor did they display any significant progression of their symptoms. As such, one would expect a relatively minimal intensity level for diagnostic treatment modalities. Furthermore, it would be most appropriate to consider certain diagnostic studies or treatment modalities only after a reasonable course of conservative management. Overutilization of either diagnostic or treatment procedures increases the likelihood of iatrogenic complications, is not cost-effective, and may adversely impact clinical and occupational outcomes."

Tacci J, Webster BS, Hashemi L, Christiani DC. Clinical practices in the management of new-onset, uncomplicated, low back workers' compensation disability claims. Journal of Occupational and Environmental Medicine 1999;41(5):397-404.