Back Pain: Too Little Exercise, Too Much Imaging

April 02, 2009

by Janis Kelly

CHAPEL HILL, North Carolina—Patients with chronic low back pain (LBP) are using too many narcotics, having too many CT and MRI scans, and underutilizing exercise and antidepressants, according to a study in the April 1 issue of Spine.¹

{}”A large majority of individuals with chronic LBP seek care from more than one provider and receive a number of tests and treatments. These tests and treatments often do not reflect the best evidence for effective treatment of this chronic and disabling condition. Some treatments, such as use of therapeutic exercise, seem to be underutilized, whereas other treatments, such as utilization of muscle relaxants, advanced imaging studies, and physical methods such as traction, TENS units, and corsets, seem to be substantially underutilized,” wrote lead author Timothy S. Carey, MD, MPH. Dr. Carey is at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill.

Dr. Carey and colleagues conducted a random telephone survey of 5357 households to identify 732 adults with chronic low back pain. The respondents were asked in detail about what back pain treatments they used. The researchers found that:

• 61% had used narcotics in the previous month
• 31% had used muscle relaxants
• over one-third had MRI or CT scans in the previous year, even though the mean duration of their back pain was nearly 10 years
• only 8.7% were taking antidepressants, but 54% had positive depression screening tests.

Treatments used don't match the research evidence

Use of research-proven treatments was relatively low. Fewer than half of the patients had a prescription for exercise, and only 30% had seen a physical therapist in the past year. Just 3% had gone through a structured rehabilitation program—one of the few treatments with moderately strong evidence of effectiveness.

As in previous studies of back pain, many patients had symptoms of depression. However, few of these patients were taking antidepressant medications or seeing a mental health professional.

“The burden of untreated or undertreated depression in this population is substantial....We recommend greater efforts toward case-finding and treatment of depression in the chronic back pain populations,” Dr. Carey said.

Back Pain: Translating research into practice

Chronic low back pain prevalence has risen over the past 10-15 years from 3.9% to 10.2% of the adult population. Dr. Carey said that there has, over that time, also been substantial progress in research to evaluate the effectiveness of various treatments for back pain. However, the results have not moved from bench to bedside.

The new results suggest that most patients with chronic low back pain see more than one health professional and receive a number of different tests and treatments. The researchers voice special concern about the overuse of narcotics and other medications and the underuse of exercise, antidepressants, and other proven treatments.

The researchers recommend "concerted efforts by professional groups, insurers, and health policy makers...to substantially change treatment patterns...for this common and disabling illness."

Reference

1. Carey TS, Freburger JK, Holmes GM, et al. A long way to go. Practice patterns and evidence in chronic low back pain care. Spine. 2009;34:718-724.