Clinical Strategies for Controlling Costs and Itnproving Quality in the Primary Care of Low Back Pain Richard A. Deyo, MD, MPH University of Washington, and Seattle Veterans Affairs Medical Center Seattle, WA Back pain is a pervasive problem which ranks only behind cold symptoms as a reason for all physician visits. Among persons with back pain lasting at least two weeks, 85% will seek the care of a health professional. These patients obtain care from primary care physicians (Family Medicine, Internal Medicine, and Osteopathic physicians), but also see a variety of specialists, including physiatrists, rheumatologists, orthopedic surgeons, and neurosurgeons. Since any of these specialties may evaluate patients early in their course, it is important to adopt a systematic and rational early approach to back pain. This discussion emphasizes recent data suggesting that such an approach would include a parsimonious diagnostic evaluation, careful attention to patients' concerns, and careful choice of proven effective treatments. Specifically, we propose five strategies that may help to reduce costs of care while maintaining quality: 1. Avoid premature or unnecessary diagnostic tests. 2. Avoid patient deactivation. 3. Avoid ineffective or unproven remedies. 4. Prescribe effective therapy in a cost-conscious manner, and Supported in part by grant no. HS-06344 from the Agency for Health Care Policy and Research (the Back Pain Outcome Assessment Team) and by the Health Services Research and Development Field Program, Seattle VA Medical Center.

5. Emphasize lifestyle changes and patient selfefficacy. Keywords: Back pain; diagnosis back pain; lifestyle change; strategies for back pain

DIAGNOSIS: AVOIDING PREMATURE OR UNNECESSARY TESTS An expert panel has estimated that up to 85% of

patients with low back pain cannot be given a definitive diagnosis. I This is primarily because of the poor associations among symptoms, pathological findings, and imaging results. This has resulted in the proliferation of controversial diagnoses and variable diagnostic criteria. 2 Rather than insisting upon a precise diagnosis, which may be impossible, the early diagnostic evaluation of patients with back pain should focus on three questions 3 : 1. Is there an underlying systemic disease causing back pain? 2. Is there a neurologic deficit which may require surgical evaluation? 3. Is there evidence of social or psychological distress that may amplifY or prolung pain? Fortunately, the clinical history and physical examination can go a long way toward answering these questions for most patients.

Clinical Evaluation to Rule Out Systemic Disease The most common and worrisome underlying systemic cause of back pain is a malignancy.

J Back Musculoskel Rehabil 1993; 3(4):1-13 Copyright © 1993 by Andover Medical.

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BACK AND MUSCULOSKELETAL REHABILITATION ! FALL 1993

Metastatic cancer and primary tumors such as multiple myeloma are far more common than spinal infections (e.g., osteomyelitis, epidural abscess) or inflammatory conditions such as ankylosing spondylitis. Even so, cancer accounts for less than 1% of episodes oflow back pain. 4 About 80% of patients with an underlying malignancy are over age SO. Every patient with back pain should be asked about a history of prior malignancy, and patients with a positive history should be carefully evaluated. Systemic signs such as unexplained weight loss, lymphadenopathy, or hematuria obviously prompt further investigation. Most patients with back pain due to cancer report that the pain is unrelieved by bed rest, and the report that bed rest does improve pain can help to rule out malignancy. In a study of nearly 2,000 patients with back pain, no malignancy was identified in any patient who was under age SO, who had no history of cancer or unexplained weight loss, and whose pain improved within one month of conservative therapy. This combination of findings can therefore be useful in ruling out cancer, and may obviate the need for further diagnostic tests. 3 ,4 Most spinal infections are blood borne from other sites, such as indwelling urinary catheters, skin infections, or injection sites for "street drugs." The presence of fever in a patient with low back pain requires further investigation. Spine tenderness to percussion is a relatively sensitive finding for bacterial infection, but nonspecific. 3

Clinical Evaluation for Neurologic Compromise The most common cause of neurologic impairment in patients with back pain is a herniated intervertebral disc. Other less common causes include nerve root entrapment by bony and ligamentous hypertrophy, spinal stenosis, spinal infections, or malignancies. Sciatica is usually the first clue to nerve root impairment, and has such a high sensitivity (about 95%) that its absence makes a clinically important lumbar disc hernation unlikely. Most patients have a long history of back pain prior to the onset of sciatica, but leg pain usually overshadows the back pain when a frank herniation occurs. 3,5

Over 95% of clinically important lumbar disc herniations occur at either the L4-S or LS-Sl intervertebral levels. For these lower lumbar nerve roots, ipsilateral straight leg raising is a moderately sensitive test for nerve root irritation, but nonspecific. In contrast, a crossed straight leg raising sign (reproduction ofleg pain when raising the opposite leg) is a highly specific sign for nerve root irritation, but relatively insensitive. Because most symptomatic disc herniations occur at the lowest two lumbar intervertebral levels, neurologic examination should emphasize ankle dorsiflexion strength, great toe dorsiflexion strength, ankle reflexes, and the sensory examination. These are the deficits most likely to occur in patients with L5 or S 1 nerve root impairments. 3 The diagnostic criteria and surgical indications for spinal stenosis are less well developed than those for herniated discs. Spinal stenosis occurs in an older group of patients (average age, SS years at the time of surgery), and most have had low back symptoms for several years. The most characteristic history is that of neurogenic claudication: pain in the legs or neurologic deficits that occur after walking. Unfortunately, only about 60% of patients who undergo surgery for spinal stenosis have this finding. 6 Typically, patients with spinal stenosis have increased pain on spine extension, as opposed to patients with herniated discs, who generally find flexion to be most painful. The cauda equina syndrome is a rare diagnosis that is made by the clinical findings. The most consistent finding is urinary retention, with a sensitivity of about 90%. About 75% of patients will have "saddle anesthesia," occurring over the buttocks, posterior superior thighs, and perineal regions. Anal sphincter tone is reduced in 60% to 80% of cases. The cauda equina syndrome is the only indication for emergent surgical referral. However, patients with severe neurologic deficits or those which progress in the face of conservative therapy should also be referred to a surgical specialist. Minor neuromotor deficits that persist after four to six weeks of conservative therapy identify another group of patients who may benefit from surgical intervention. However, the long-term

Controlling Costs and Improving Quality

prognosis for both pain and neurologic recovery is highly favorable even without surgery, so that patient preferences should play an important role in treatment decisions. Finally, patients who have persistent sciatica, sensory deficit, or reflex loss after four to six weeks and who have consistent clinical findings and favorable psychosocial circumstances may also be surgical candidates. Several studies have shown excellent results from rehabilitation interventions in this group, however, so patient preferences are again important. 7,8 Note that these surgical indications are largely based on clinical findings. Many observers now argue that sophisticated imaging tests should be used mainly for surgical planning, and therefore would be indicated only in patients who have clinical indications for surgery, and for whom conservative care is failing. 9 ,10

3

Are There Factors That May Amplify or Prolong Pain? An important goal of the clinical history is to identify patient features which influence management regardless of underlying pathology. Chronic pain or depression may be indications for use of antidepressant medication rather than narcotic analgesics. Findings of alcohol or drug abuse will influence the choice of medications and may benefit from specific intervention. Evidence of psychological distress should be sought, because conditions such as depression may respond to direct intervention and improve the likelihood of response to other treatments. Waddell has identified a number offeatures of the history and physical examination which may be markers of psychological distress. Table 1 lists these findings, which may indicate a need for

Table 1. A comparison of the symptoms and signs of physical disease and illness behavior in chronic low back pain and sciatica. Physical Disease Normal Illness Behavior

Pain drawing

Abnormal Illness Behavior

Pain adjectives

Localized Neuroanatomical Proportionate Sensory

Nonanatomical Regional Magnified Affective Emotional

Symptoms Pain

Localized

Whole leg pain Tailbone pain Whole leg numbness Whole leg giving way Never free of pain Intolerance of treatments Emergency admission to hospital

Numbness Weakness Time pattern Response to treatment Signs Tenderness Axial loading Simulated rotation Straight leg raising Sensory Motor General response

Dermatomal Myotomal Varies with time Variable benefit

Localized No lumbar pain No lumbar pain Limited on distraction Dermatomal Myotomal Appropriate

Superficial Widespread nonanatomical Lumbar pain Lumbar pain Improves with distraction Regional Regional, jerky, giving way Overt pain behavior

From Waddell, G. Biopsychosocial analysis for low back pain. Balliere's Clinical Rheumatol1992; 6:523-557. With permission.

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BACK AND MUSCULOSKELETAL REHABILITATION / FALL 1993

further psychological evaluation and suggest caution in the use of invasive tests or treatments.

Use of Plain X-rays In the past, the use of plain x-rays was usually considered routine in the management of patients with low back pain. However, many observers have recently pointed out the important limitations of plain spine x-rays, and suggested that they are overutilized. 10-15 Some of the factors limiting the utility of plain films are:

• A low yield of useful findings in patients under age 50 (one in 2,500 in a lO-year Swedish study). 13 • Many radiographic anomalies are equally common in symptomatic and asymptomatic persons (e.g., spina bifida occulta, single disc narrowing, spondylosis, facet joint abnormalities, several congenital anomalies). 13 Table 2.

• Gonadal radiation exposure is substantial. 15.16 • There are frequent disagreements in x-ray interpretation, even by expert radiologists. 17 • The aggregate costs are substantial. 15 • Simply obtaining x-rays appears to create the patient expectation of imaging for every patient with back pain. 18

These limitations have led several experts to suggest more selective use of plain radiography. Sample criteria and their rationale are shown in Table 2. Furthermore, there is growing evidence that the traditional five-view x-ray (AP, lateral, two obliques, and a coned lateral of the L5-S1 junction) is unnecessary for the vast m~jority of patients with back pain. At least five studies have shown that a very small number of diagnoses are missed by omitting these views, and those diagnoses in

Clinical findings that should prompt early radiography. Finding

Age ;;::50 yr Significant trauma Neuromotor deficits

Unexplained weight loss (;;:: 10 lb in 6 mo) or lymphadenopathy Suspicion of ankylosing spondylitis (see text) Drug or alcohol abuse

History of cancer (other than skin cancer) Fever (temperature> 100°F or 37.8°C) Use of corticosteroids Failure to improve after 2-4 wks of conservative therapy Seeking compensation

Rationale

More likely to have underlying malignancy, osteoporosis, compression fractures Fracture more likely IdentifY underlying spondylolisthesis or malignancy (more common causes such as herniated disc or spinal stenosis will not be apparent on plain films) Malignancy or chronic infection more likely Identiry inflammatory spondyloarthropathies IV drugs increase risk of spinal osteomyelitis; alcohol increases risk of osteoporosis; both increase risk of trauma, often poorly remembered Metastatic disease more likely Often found with osteomyelitis or epidural abscess Increased risk of osteoporosis and infection Up to 90% of patients with acute low-back pain improve within 1 month; failure to improve may indicate underlying systemic disease Sometimes involves physical injury; x-ray evidence needed for most legal proceedings

Adapted from Deyo RA: Lumbar spine films in primary care: Current use and the effects of selective ordering criteria. J Gen Intern Med 1:20-25. 1986.

Controlling Costs and Improving Quality

turn rarely affect therapy. 19-23 As a result of such studies, the World Health Organization has published a monograph recommending that oblique views not be routinely obtained but reserved for special problems after review of AP and lateral films.24 Limiting the routine lumbar spine x-ray to an AP and lateral would eliminate two-thirds of the radiation exposure and costs. The Quebec Task Force on Spinal Disorders concluded that in the absence of neurologic deficits, plain radiography was inappropriate for patients with pain of less than one week duration, and of uncertain value in those with one to seven weeks of pain. After seven weeks duration, they suggested that plain radiography would generally be appropriate. 25 At least in primary care, the use of selective x-ray criteria such as those above has been shown not to miss important radiographic findings, while substantially increasing the yield of therapeutically important results. II ,I2,I4 It appears that offering patients a simple explanation about their back pain and the disadvantages of early radiography can substantially reduce patient expectations. In a randomized trial, we demonstrated that patients randomly allocated to receive a five-minute educational intervention or early radiography were equally satisfied with their medical care and had a similar course of recovery. While some of those assigned to the educational intervention subsequently received x-rays, their total radiography costs remained far below those of the group who got routine early radiography. Furthermore, expectations about the need for x-rays among patients with back pain were substantially lower than among those who received plain films. 18

Laboratory Tests Laboratory tests are unhelpful in diagnosing the common causes of back pain or nerve root compression. Their only value is to help rule out systemic diseases. Because systemic illness is a rare cause of back pain, most positive laboratory tests are likely to be false positives. However, several studies suggest that for selected high risk patients, the erythrocyte sedimentation rate (ESR) may be a useful screening test for serious underlying causes of back pain such as cancer or infection. 4,26,27 Because it is sensitive, a normal ESR helps "rule

5

out" systemic disease; because it is nonspecific, however, a positive test requires further investigation. The value of the HLA-B27 histocompatibility antigen is much more limited. Although it is significantly associated with inflammatory spondyloarthropathies, only a minority of persons with the antigen actually have anklylosing spondylitis. Thus, most positive tests are "false positives" as tests for anklylosing spondylitis. 28 Furthermore, typical x-ray findings establish the diagnosis without the use of this test. Thus, its value is primarily for patients with equivocal x-ray changes who appear clinically to have a moderate probability of having anklylosing spondylitis. Even in this situation, a latcr radiograph to confirm the diagnosis would be necessary. 29

Advanced Imaging Procedures Modern computed tomography (CT) and magnetic resonance imaging (MRI) are both slightly more accurate in the diagnosis of herniated discs and spinal stenosis than plain myelography. Furthermore, high quality MRI is probably as accurate as CT myelography.30 Thus, the need for the invasive procedure of myelography, with its substantial risk of headaches, and smaller risk of other complications, has declined dramatically. Because thcy are not invasive, CT and MRI scanning are associated with fewer side effects and lower costs than myelography. This fortunate circumstance has led to a less desirable result: widespread and early use of CT or MRI in evaluating acute low back pain and sciatica. This practice is unfortunate, because the specificity of even these imaging procedures is only moderate. That is, many persons who have never experienced back pain or sciatica will demonstrate CT and MRI abnormalities. 9,31,32 Table 3 shows the prevalence of various imaging abnormalities among normal subjects with no history of back problems. Because many anatomic abnormalities are incidental, they may initiate an ill-advised cascade of clinical events, simply because the physician and patient feel compelled by the imaging results to proceed. When this occurs in the absence of objective neurologic findings, surgical results are likely to be disappointing. Thus, many experts suggest that these imaging tests should only be used if a patient is a potential surgical

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BACK AND MUSCUWSKELETAL REHABILITATION / FALL 1993

Table 3. Computed tomography and magnetic resonance imaging results on normal subjects. CT Results: "Normal Subjects" (N = 52)

Age Herniated disc Spinal stenosis Facet abnormality Any abnormality

Under 40

Over 40

20% 0% 0% 20%

27% 3% 10% 50%

From Wiesel et al. Spine 1984; 9:549.

MRI Results: "Normal" Subjects (N = 67)

Age Herniated disc Spinal stenosis Bulging disc Degenerated disc

Under 60

Over 60

22% 1% 54% 46%

36% 21% 79% 93%

From Boden et al.:] Bone]oint Surg 1990; 72-A:403.

candidate, at which time the findings can be used to assist in planning surgery. 10

Avoiding Unproven Tests Several new, expensive, but unproven technologies for back pain diagnosis or evaluation are currently in widespread use. In some cases, there is little scientific evidence to support their use, and in some cases there is evidence which should discourage their use. An example is lumbar thermography, which is advocated by some as a test for lumbar nerve root compression. A comprehensive meta-analysis of the literature concerning thermography demonstrated extensive methodologic ft.aws which would tend to exaggerate the accuracy of the test. Even so, results of these studies suggest that while thermography may be sensitive, it is quite nonspecific, and therefore has little ability to discriminate persons with true radiculopathy from those without. 33 Another controversial diagnostic test is lumbar discography, which has prompted diametrically opposing editorials from the North American Spine Society and the European editor of

Spine. 34 ,35 The literature on the use of this test is confused by uncertainty as to the proper "gold standard" for judging its accuracy, ambiguity about its goals, and a near absence of data on the reproducibility of its interpretation. In part, the test is designed to demonstrate internal degenerative derangements of the intervertebral discs, but these increase with aging, and are increasingly detectable with magnetic resonance imaging. The other major aspect of discography is the pain response, which is subjective and of unknown reliability. Because it is both invasive and expensive, this test should probably be used with caution. Various devices for computerized trunk dynamometry have become popular with the claim that they can diagnose malingering, and help to plan and monitor physical therapy. It remains unclear and controversial whether these expensive devices offer additional information above and beyond simpler measurements of strength and range of motion that can be performed manually.

Avoiding Self-Referral Imaging "Self-referral" is the practice of referring patients for imaging to a facility which is fully or partly owned by the referring physician. This has become an increasingly common practice, and is exemplified by the physician who has plain radiography available within his own office. Recent studies have demonstrated that the use of plain x-rays and other imaging tests is substantially higher for self-referral practices than for those who refer patients to a radiologist. 36,37 In particular, for low back pain, self-referring physicians are almost four times as likely as others to obtain imaging, resulting in imaging charges 2.5 times greater per episode of back pain. Though professional organizations are moving to discourage this practice, the cost-conscious clinician will identity where it is occurring, avoid it within his own practice, and avoid referrals to such practices.

THERAPY: AVOIDING PATIENT DEACTIVATION Brief Bed Rest Although bed rest has long been a mainstay of therapy for acute low back pain, there is growing

Controlling Costs and Improving Quality

evidence that, for most patients, brief if any bed rest is sufficient. There is physiologic evidence suggesting that the supine posture reduces intradiscal pressure and may benefit patients with acute sciatica and a probable disc herniation. However, most patients with low back pain in the absence of sciatica probably have disorders of muscles, ligaments, or other spinal structures, rather than disc herniations. For such patients, any physiologic rationale for bed rest is unclear. Furthermore, the upright posture produces disc pressures that are only slightly higher than those in the side-lying posture. 13 Two recent randomized trials from primary care practices have suggested that brief if any bed rest is necessary for most patients with uncomplicated back pain. In our study, patients were randomly allocated to recommendations of two days or seven days of bed rest. No differences were observed in the speed of pain resolution, functional recovery, or satisfaction with care, although those assigned to the two-day recommendation missed 45% fewer days of work than those assigned to seven days. This was true even though compliance with the bed rest recommendation was highly variable. 38 In a study of similar design, patients in a family practice were randomly allocated to zero days of bed rest versus four days. Follow-up demonstrated no detectable differences in the speed or extent of pain resolution, but the group with no bed rest returned to their normal activities 42% sooner than those in the bed rest group.39 Both of these studies excluded patients with neurologic deficits. In our study, the assigned bed rest recommendation was the best predictor of subsequent work loss for the three-month interval after enrollment. Clinical data such as pain severity, duration, prior episodes, spine flexion, and straight leg raising did not significantly predict work loss.38 Depending on job demands, of course, return to work may need to be more gradual, and heavy lifting may have to be temporarily avoided. However, it appears that most persons can at least resume standing activity without fear of delaying recovery or causing permanent harm. Since strict or lengthy bed rest is generally unnecessary, hospitalization for this purpose should be avoided.

7

The recommendation of lengthy bed rest that was frequently prescribed in the past may have contributed to what has been labeled the "disuse syndrome."4o This is a syndrome ofsedentariness and subsequent loss of cardiopulmonary and muscle fitness which has its own ill consequences. Certainly, the loss of muscle mass and cardiopulmonary fitness have been documented to occur rapidly during bed rest, as has bone demineralization. Bed rest may also contribute to anxiety, depression, and disease conviction, as well as loss of interest and motivation. To the extent that such factors lead to slower return to normal activities and to additional use of medical services, they may contribute to the costs of back problems. Thus, the best-documented economic result of briefer bed rest is a reduction in work absenteeism and the "indirect cost" of back pain. However, there is reason to believe that shorter bed rest prescriptions may also result in reduced direct medical care costs in the long run.

Labeling and Reassurance The prognosis of acute back pain is quite good. While recurrences are common, they generally also resolve quite rapidly. Even among the minority of patients with back pain who miss work as a consequence, return to work is rapid, with a majority back in the workplace within six weeks. 25 Thus, patients should be reassured that back pain is rarely a truly disabling condition and that the natural history is one of rapid recovery and return to activity. Backache is an extremely common symptom, and its pathophysiology or anatomic causes are often obscure. Thus, it seems wise to generally avoid use of the term "back injury," which implies to patients anatomical disruptions and torn tissues. The term "injury" itself may lead patients to a perception of fault and the need for legal redress. Other terms, such as "ruptured disc" and "degenerative arthritis" elicit fear on the part of many patients. They imply broken body parts and deteriorating organs, which patients anecdotally recount with frightening mental images. This occurs despite the fact that herniated discs are frequently demonstrable in asymptomatic persons, and the fact that spinal degenerative changes are I

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BACK AND MUSCULOSKELETAL REHABILITATION / FALL 1993

as ubiquitous as gray hair and wrinkles in the aging population. It seems likely that physicians will cause less alarm, concern, and dependency by avoiding such frightening terms and providing more reassuring explanations of symptoms, which may accurately invoke such terms as "changes due to wear and tear." Waddell has demonstrated that fear of experiencing permanent harm as a result of physical activity and work may be a specific and powerful deterrent to returning to work. He suggests that "fear of pain ... appeared to be more disabling than pain itsel£"41 Ultimately, the goal is to avoid as much as possible having a "patient" become a "claimant."42 Once patients are claimants, they must continue to demonstrate that they are sick, and become embroiled in an adversarial contest often based on weak causal assertions and judgmental treatment by health care providers. At this point, to improve would be to risk both financial reward and one's own credibility. Furthermore, when physicians are completely reimbursed by workers' compensation for extensive diagnostic and therapeutic interventions, there is little incentive for restraint in clinical management. Thus, the primary care physician should resist both frightening language and the pressures to perform unnecessary tests or procedures. Patients should understand the intent and pitfalls of compensation and disability insurance, and physicians may often need to encourage supervisors to permit part-time or limited return to work. Such efforts may help to make the patient's good intentions clear and help the patient to avoid loss ofthe work habit, ultimately dissuading some from becoming long-term claimants.

THERAPY: AVOIDING INEFFECTIVE OR UNPROVEN REMEDIES Unorthodox Treatments A recent study suggested that back pain was the most common reason for patients to seek unorthodox forms of health care. 43 While some of these forms of health care, such as chiropractic, are gaining in credibility as treatments for low

back pain,44 others have no scientific evidence of efficacy. Examples include "Chinese finger pressure," "reflexology," and many other forms of healing gimmickry. Yet other forms of unorthodox treatment, such as acupuncture, remain controversial, but are at least being subjected to scientific scrutiny. Patients are most likely to seek out such unorthodox therapy when they perceive hostility or disinterest on the part of the medical profession, a common attitude toward patients with low back pain. We may discourage such "healer shopping" by establishing better rapport with our patients and trying to establish a true therapeutic alliance.

Unproven Therapy by Medical Physicians Even orthodox practitioners are sometimes guilty of proliferating unproven treatments in an uncritical manner. Examples of recent fads would include colchicine therapy for back pain, and laser stimulation of trigger points. 45 Furthermore, many widely used traditional treatments have no scientifically acceptable evidence of efficacy, and some even have substantial evidence of inefficacy. There are now several randomized controlled trials of lumbar traction with surprisingly concordant negative results. 5 In addition, there are now multiple randomized trials offacetjoint injections, all with negative results. 46,47 Recent studies have challenged the ability of trained clinicians to reliably detect trigger points,48 and have suggested that the results oflocal anesthetic injections are no different than needling without injection, saline injection, or vapocoolant spray.49 The value of transcutaneous electrical nerve stimulation (TENS) remains controversial, with one large recent randomized trial 50 and several smaller studies 51 ,52 suggesting that TENS may be no more effective than sham TENS. Similarly, the Quebec Task Force concluded that there was no scientific evidence for the effectiveness of treatments such as biofeedback and corsets. 25 Since all these forms of therapy involve costs, some potential side effects, and the risk of encouraging dependency, we should insist on better evidence before widespread use.

Controlling Costs and Improving Quality

Repeat Back Surgery It is not unusual in many chronic pain clinics to encounter patients who have had five or more lumbar spine operations. This occurs despite evidence that the satisfactory outcome rate falls with each successive operation. Most would agree that a new disc herniation, accompanied by all of the signs, symptoms, and imaging criteria that applied to a first herniated disc, constitutes a valid indication for reoperation. However, many reoperations are undertaken wit.hout such evidence, and in the face of more speculative pathophysiologic inferences. As shown in Table 4, the results of such repeat surgery are hardly gratifying. 53 Furthermore, there is a growing belief that too much lumbar spine surgery is performed in the United States. An international survey demonstrated that our rate is at least twice that of most developed nations, 54 and national survey data show that it has risen approximately 50% over the past decade (Taylor, et ai., unpublished data). An expert panel convened by the Institute of Medicine recently concluded "that surgery for chronic back pain is overused and often misused ... and that back surgery (especially repeated surgery) frequently results in serious iatrogenesis."55 A senior orthopedic surgeon has wryly noted that "All too often, wellintentioned surgeons who carry out repeat lumbar spine surgery are bludgeoned into the realization that no matter how severe or intractable the pain, it can always be made worse by surgery."56

Table 4.

9

PRESCRIBING EFFECTIVE THERAPY IN A COST-CONSCIOUS MANNER Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Several NSAIDs have been shown to be effective for low back pain in randomized trials. Positive trials have been reported for at least diflunisal, piroxicam, and naproxen sodium,57-60 and most drugs in this class are probably efficacious. However, these drugs have frequent side effects, and their efficacy has not. generally been demonstrated to exceed t.hat of aspirin or other simple analgesics. The choice of such medications has a large financial impact, with the monthly cost of treatment ranging from about $6.00 per month for plain or enteric-coated aspirin to over $100.00 per month for piroxicam, diflunisal, ketoprofen, and fenoprofen (using wholesale prices).61 The costs associated with gastrointestinal (GI) and renal side effects add to this cost. While the newer NSAIDs are probably no more effective (or only slightly more effective) than moderate to high dose aspirin, they probably produce less GI distress. However, acetaminophen has been shown to be as effective as ibuprofen in relieving pain from osteoarthritis,62 and generic sodium salicylate and salsalate are effective analgesics. In high doses, they also have anti-inflammatory properties and their costs are in the same range as enteric-coated aspirin and generic ibuprofen. At least with chronic use, GI side effects and GI bleeding may account for a substantial fraction of the costs of treating musculoskeletal pain with

Results of repeated operations among Toronto men covered by workers' compensation.

P-atient Evaluation Improved Worse Observer Evaluation Good Poor

2nd Procedure

3rd Procedure

4th or 5th Procedure

53% 19%

35% 25%

27% 45%

23% 60%

5% 90%

0% 90%

Adapted with permission from Waddell G, et al.J BoneJoint Surg 1979; 51-A: 201-207.

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BACK AND MUSCULOSKELETAL REHABILITATION / FALL 1993

these drugs. While misoprostol has recently been marketed for reducing this risk, recent reviews recommend against routine prophylactic use of misoprostol. 63 Furthermore, diarrhea is a common side effect. For patients who cannot avoid NSAID therapy and are at high risk of serious complications from gastric ulceration, misoprostol may be prudent. However, all of these considerations have led the authors of a recent review to suggest strategies for even more cost-conscious prescribing of NSAIDs.61 These strategies include: 1. Use of an analgesic with minimal side effects due to cyclo-oxygenase inhibition. These include acetaminophen and generic salsalate. 2. If anti-inflammatory effects are desired, consider high-dose nonacetylated salicylates or generic ibuprofen. 3. Avoid use of more than one NSAID simultaneously. 4. Start at small doses and increase only if necessary. 5. Allow up to two weeks for maximal antiinflammatory effects, and limit initial prescriptions to this amount. 6. If several NSAIDs are tried and none is clearly superior, return to the least expensive drug that was well tolerated. 7. Reserve prophylaxis for upper GI side effects to patients thought to be at high risk. 8. If renal impairment from NSAIDs is a problem, generic salsalate is the least expensive of "renal sparing" drugs.

Setting Limits on Physical Therapy The costs of physical therapy are highly dependent on personnel costs and the number of visits incurred by a patient. When treatment benefits plateau, there is usually little need for continued physical therapy, and visits should be limited. Unfortunately, recent studies have demonstrated that when physical therapy facilities are owned by the referring clinician, use tends to be higher than in other circumstances. 64 In a workers' compensation population, physical therapy was initiated 2.3 times more often when selfreferral was involved than in the independent

referral situation. This is analogous to the problem of self-referral imaging, and should be avoided whenever possible.

LIFESTYLE CHANGE AND PATIENT SELF-EFFICACY Some risk factors for back problems and recurrences are not amenable to medical intervention. These include factors such as age, education, and occupation. However, other risk factors are lifestyles which are amenable to change, though this may be difficult to produce. These risk factors include cigarette smoking, sedentariness, and obesity. Epidemiologic studies suggest a "dose response" between each of these factors and the likelihood oflow back pain.65 Thus, there may be opportunities for primary physicians to reduce the risks of back pain and related disability by intervening to improve these three lifestyles. There is a growing literature on the efficacy of various treatments for smoking cessation and weight loss, and these may have multiple health benefits. There is also growing evidence for the value of therapeutic exercIse of various types.41 ,50,66 Furthermore, these activities, and especially involvement in exercise, may provide the patient with a sense of empowerment and greater "selfefficacy." To the extent that patients feel they have some ability to control and modifY back symptoms, they may be less dependent on medical care and utilize services more parsimoniously.

SUMMARY We have discussed five strategies for reducing the costs of care for low back pain. Based on currently available evidence, these strategies should not diminish the quality of care, and may even improve it. These strategies require no government regulation and no rationing of effective therapy. Many uncertainties remain with regard to the diagnosis and treatment of back pain, of course, but clinicians should remain appropriately skeptical of innovations until they are supported by strong

Controlling Costs and Improving Quality

evidence. Only in this way will we avoid falling prey to the expensive succession offads and fash-

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ions that have dominated the care of back pain for many years.

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