How do physicians decide what treatment recommendations to make for patients with acute (early onset) of low back pain? Is it based on whether that patient is a man or woman (suggesting a sex-biased health plan of care)? Does the patient's socioeconomic status (SES) such as lifestyle, occupation, and education make a difference? And how much does the clinical presentation affect the decision-making process (especially if that presentation is from an emotional female)?
These are the questions put forth by the authors of this study. They surveyed 284 physicians from five different clinical sites (both primary care physicians and emergency department physicians). They asked questions about physicians' decisions related to patients with low back pain.
Physicians were given a case scenario of a patient with recent onset of low back pain. After giving a written summary of the patient's characteristics, physicians were asked about the diagnostic approach and treatment they might choose for this patient. Analysis of the data took into account the type of treatment recommended based on the three factors already mentioned (sex, socioeconomic status, and clinical presentation).
Each of these three variables was analyzed based on diagnostic tests physicians would order and the type of treatment recommended. Some of the diagnostic options included blood tests, urinalysis, X-ray, CT scan, MRI, or discography. Of course, no diagnostics was an option, too.
On the treatment side, physicians could recommend no treatment or referral to another physician (specialist), physiotherapist, chiropractor, osteopath, or psychologist. Choices of specialists included orthopedic surgeon, physiatrist (physician who specializes in rehabilitation services), neurologist, gynecologist (for women), and anesthesiologist.
For half the physicians, no diagnostics and referral were recommended. Patients were given instructions to stay as active as possible, use heat or cold, and take pain relievers as needed (e.g., ibuprofen or other antiinflammatory). The natural course of the back pain would be explained and an educational pamphlet provided. Almost all physicians recommended a follow-up visit. When referral was recommended, it was most often to a physiotherapist.
Of particular interest in the results was the apparent link between socioeconomic status (SES) and activity recommendations. It seems physicians were more likely to encourage patients to remain active if they were white-collar workers (higher SES status) and male. Blue-collar workers (e.g., manual laborers) and women were more likely to be told to take it easy, rest, and restrict heavy lifting or other manual work at home and at work.
The other nonclinical factor that seemed to influence physicians' treatment decisions was the clinical presentation. Patients who expressed distress about their back pain were more likely to be given a prescription for medications. Though not stated, the authors presumed this behavior on the part of physicians was to reduce the patient's suffering.
However, there is no scientific evidence that such treatment is beneficial or yields any better results than doing nothing. And there is plenty of evidence that staying active will improve outcomes. Clinical practice guidelines for the treatment of acute low back pain have been previously published.
One of the recommendations supported by studies is the use of chiropractic care for acute low back pain. Despite evidence to support this treatment option, not one of the physicians surveyed chose manipulation. Physiotherapists perform manipulations but manipulation as a treatment option was not specified as chiropractic or physiotherapy.
The authors summarized their findings by saying that this study provided more evidence that for the most part, primary care and emergency department physicians are not treating patients with acute low back pain according to current clinical practice guidelines. Instead, they are being influenced by patient characteristics such as gender (female versus male), socioeconomic status, and complaints of pain, distress, and suffering.
Reference: Shira S. Weiner, PhD, et al. Managing Nonspecific Low Back Pain. In Spine. November 1, 2011. Vol. 36. No. 23. Pp. 1987-1994.
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