■ Spine-related pain is the largest cause of disability in the world with enormous global economic impact.
■ Large increases in expenditures for care have not resulted in improved clinical outcomes.
■ The biomedical model plus practitioners separated by licensure and isolated in specialty-based silos have contributed to a dysfunctional state of care.
■ Emerging integrative models of care that consider biopsychosocial approaches plus diagnostic and/or symptom-based stratification offer the potential for improved value (efficacy, clinical outcomes, and reduced cost).
■ Successful implementation of a pathway approach utilizes a primary spine practitioner who can care for the majority of patients and is capable of triage in circumstances in which comanagement or referral is warranted.
Spine pain, and low-back pain (LBP) in particular, are prevalent, costly, and a challenge to diagnose, treat, and study. Eight out of ten people are affected at some time in their lives.1 LBP is a major problem throughout the world with a point prevalence of 11.9 ± 2.0% and a one-month prevalence estimate of 23.2 ± 2.9%.2 It is also the leading cause of disability worldwide contributing to 10.7% of the total and has a greater impact on global health than malaria, tuberculosis, preterm birth complications, COPD, diabetes, or lung cancer. When combined with neck pain, the fourth leading cause of disability worldwide, the impact on global health is greater than HIV/AIDS, Alzheimer’s disease, malaria, diabetes, lower respiratory infections, depression, stroke, traffic injuries, or the combination of breast and lung cancer.3,4
LBP is not only prevalent, but has enormous economic consequences. Annual cost estimates in the U.S. alone could exceed $600 billion. There have been eight foreign, methodologically rigorous studies of the economic burden for LBP but no such similar studies in the United States. By applying the median proportion of direct (14.5%) versus indirect (85.5%) costs obtained from the eight international studies, prior US estimates for direct costs ($12.2 to $90.6 billion) might similarly represent 14.5% of total costs. If so, the total US costs range from $84.1 to $624.8 billion. Until such a comprehensive US study is completed, we are left with uncertainty about the exact economic burden but we do know that it is extraordinary and is associated with considerable suffering.5
Studies suggest the problem is worsening, both economically and clinically. There was a 95% increase in inflation-adjusted annual expenditures on specialty care services for ambulatory LBP in the United States between 1999 and 2008 without appreciable, corresponding improvements in clinical outcomes.6 During a similar period, disability related to spine pain, including work or school limitations, physical functioning, and mental health status, worsened.7,8 In spite of increased intervention and enormous costs, there has not been an appreciable decrease in the incidence or prevalence of LBP.9
How Spine and LBP Problems Became This Severe
In practice, treatment is seldom just one procedure or approach. The clinical tools available to manage LBP are many—maybe too many. What might the same spine pain patient get if she visited a medical primary-care physician or an orthopedic surgeon? What about seeing a physical therapist or an acupuncturist? How about seeing a rheumatologist, chiropractor, psychotherapist or massage therapist? Each of these practitioners may offer valuable contributions to manage this particular patient, but, for all practical purposes, these practitioners are typically in what might be termed as “silos,” separated by training, licensure, and the infrastructure of healthcare practice and reimbursement. Differing terminology, lack of mutual respect, and lack of communication also contribute to the existence and persistence of these silos.
Even within professions and specialties, there are many management options, each with supporters and detractors, some with favorable studies, others with studies that do not support the practices, and other options have been subjected to little or no formal investigation whatsoever. The lack of widely accepted and clearly articulated approaches to successful management of LBP is a source of confusion for healthcare practitioners and patients alike. Haldeman and Dagenais have referred to this as the “supermarket approach” in which consumers and practitioners are confronted with a vast array of possible approaches offered by multiple professions, subspecialists, and even commercial product vendors. This orientation focuses on the practitioner or supplier, rather than patients, and decisions are sometimes made based on marketing, perceptions, or salesmanship rather than evidence-based practice.10
Furthermore, an emphasis on pain control, often at the expense of restoring function, has led to the unintended consequence of increased opioid use and abuse in the United States with a concurrent decrease in the use of nonaddictive medications between 2000 and 2010. G. Caleb Alexander of Johns Hopkins Bloomberg School of Public Health states: “We found that not only have the rates of treated pain not improved, but in many cases, use of safer alternatives to opioids, such as medicines like ibuprofen and acetaminophen, have either stayed flat or declined.”11
Further fracturing the landscape is the dominant Western model of disease, the so-called biomedical model, which took root during the European Renaissance. Prior to that, Europeans, like traditional East Asian and other non-Western healthcare systems of the present and past, typically viewed mind and body as part of the same, inseparable system. Beginning in the Renaissance, European, and subsequently North American, medical practice looked increasingly to aberrant somatic bodily processes, such as biochemical imbalances or neurophysiological abnormalities, to explain illness. The assumption was that psychological and social processes were largely irrelevant to the disease process.12 This medical “breakthrough” was perceived to be an advancement over superstitions of the past. Perhaps most significantly, seventeenth-century scientist and philosopher, René Descartes (1596–1650), made a systematic distinction between the mind and the body. The mere fact that it is common practice to use the separate terms, mind and body, rather than a singular descriptor, demonstrates how forcefully Cartesian dualism continues to shape our perception.
When It Comes to LBP, Can We Even Know Exactly What We Are Trying to Treat?
Although the biomedical model may have benefits for identifying and treating some diseases, LBP presents a unique challenge. Jacob recounts recognition of biomedical model shortcomings in the late 1970s when literature began to note that there was no absolute relationship between tissue damage and the severity of pain experienced.13 Pain and disability are poorly correlated with anatomical abnormality and/or physical impairment, such as might be identified with physical-examination procedures or diagnostic studies. Postural abnormalities, disc degeneration, spondylosis, and disc protrusions, to name but a few, are findings that do not predict whether someone will suffer from LBP or respond well to intervention.
Serious underlying pathologies may account for less than 2% of LBP. Some eminently qualified authorities have concluded that defined pain generators account for no more than 10% to 15% of LBP, leaving approximately 85% of LBP described as nonspecific, mechanical back pain.14 Bhangle et al. conclude that LBP, in most cases, has no recognizable cause and most episodes are not predictable.15 Among many clinical guidelines specifically constructed to aide practitioners in making evidence-based clinical decisions, few recommend identifying pain generators once potentially serious pathology, substantial neurological involvement, or a small percentage of clinically significant anatomical abnormalities are ruled out. An aggressive search for the elusive source of pain appears to have unintended consequences. In a study published in 2013, patients who had early MRI scans experienced much more intensive medical care, with substantially higher post-MRI costs (exclusive of the cost of MRI itself) but with no evidence of better outcomes. The authors presume the increased services may have been due to the medicalization of clinically irrelevant findings leading to patients’ requests for more intensive interventions.16 Deyo reached a similar conclusion twenty years ago and noted that obtaining an early MRI may be the first indication of a cascade pattern of care that is characterized by overprescribing, overtesting, intensive and ineffective treatment, and, ultimately, poor outcomes.17 In this context, many authorities state that a specific pathoanatomic cause cannot, or perhaps should not, be sought for the vast majority of patients with LBP, essentially labeling it a homogeneous entity until further investigation proves otherwise.5,18
The view that LBP is largely a nonspecific, homogeneous entity is not without controversy. Other authorities consider it to be heterogeneous based on validated diagnostic assessments or symptomatic subclassifications.19,20 Murphy and Hurwitz21 and Murphy, et al.22 conclude that causative factors of LBP, many of which have known reliability and validity, identify relatively specific diagnostic and clinical parameters that can inform management decisions and improve clinical outcomes. They cite evidence correlating signs, symptoms, and findings with three broad categories: (1) neurophysiological (discogenic and radicular), (2) somatic (e.g., facet joints, instability, segmental dysfunction, and myofascial) and (3) psychosocial factors. With such, the practitioner can arrive at what the authors call a diagnosis-based clinical decision guide that addresses the most important factors for each individual patient and guides management strategies. The diagnosis-based clinical decision guide has been further refined and is described by Murphy as the Clinical Reasoning in Spine Pain (CRISP) Protocols.23
Management matched to features unique to a particular patient is thus expected to have a high predictive value of a clinically successful outcome. Although attempting to arrive at a diagnosis may sound like the biomedical model, with its pursuit of defined anatomical pathology and diseased tissue, this approach is multifaceted, includes psychosocial factors, and recognizes that a strict diagnosis may not always be possible, in which case treatment approach is based on patterns of symptomatic relief.
Kent and Keating point out that classification-based treatment for LBP has been practiced informally as practitioners make clinical decisions based on clinical experience and pattern recognition.24 McKenzie long ago made distinctions regarding patient management based on patient characteristics not necessarily related to diagnosis. In 1995 Delitto et al. proposed a treatment-based classification approach, acknowledging the pioneering contributions of McKenzie and Cyriax before him.25 The aforementioned diagnosis-based clinical decision guide and CRISP Protocols also lead to management strategies based on characteristics peculiar to each patient.
In this way, the sea of homogeneous LPB with conflicting and inconclusive evidence for treatment efficacy can be systematically divided into heterogeneous diagnoses and symptomatic presentations, including various degrees of psychosocial involvement, all with deliberately designed treatment approaches. Matching treatment groups to prognostic groups, rather than applying a singular treatment group such as manipulation across all prognostic groups, should lead to greater success in identifying efficacious treatments. This approach is noted in Figure 42.1S.
A key component to matching a particular patient’s management to the best probable outcome is assessing the patient for so-called barriers to clinical recovery, some of which are psychosocial. In 2001, Buchbinder et al., concluded, “There is now convincing evidence that psychosocial factors, more than biomedical or biomechanical factors, are strongly linked to the transition from acute to chronic back pain disability.” This was based on a successful campaign to alter the beliefs of the general population and medical physicians in Australia, resulting in reduced incidence and cost of workers’ compensation cases compared to controls. Follow-up studies three and four-and-one-half years after the original campaign found lasting benefits.26,27 Waddell makes a compelling case that biopsychosocial issues are strong predictors of return-to-work outcomes and states, succinctly, “Biopsychosocial problems need biopsychosocial solutions, and rehabilitation should address all these issues, tailored to meet individual needs.”28
Jacob cautions that those unfamiliar with biopsychosocial issues may assign blame to a patient for failing to improve rather than understand the practitioner’s responsibility for effective communication, education, and management such that the psychosocial aspects, in addition to biological aspects, are addressed.29 Some may also mistakenly understand, perhaps due to Cartesian dualism, that psychosocial involvement means a patient’s pain is not real when in fact psychosocial involvement is significant because psychological states such as fear can and do affect biological processes such as nociception.
How Should assessment of a Patient’s Psychosocial Status Occur?
A recently validated assessment tool aims to stratify patients with LBP into treatment categories based on the prognosis for poor clinical outcomes. It does so, in part, by addressing involvement of biopsychosocial predictors of poor outcomes including movement-related fear, catastrophization, anxiety, and/or depression. Developed at Keele University, England, the STarT Back Screening Tool (SBST) consists of nine questions that stratify patients into one of three categories with corresponding recommended management. These questions and scoring for the SBST are listed in Figure 42.2S and 42.3S, respectively.30 Patients screened with SBST and treated in the corresponding categories (Table 42.1) had superior short and long-term disability, quality-of-life measures, and cost savings compared with controls who received treatment considered to be current best practice.30 Use of SBST has been validated in various clinical settings including physical therapy and primary care. Its use appears to provide important prognostic information that enhances the management of LBP while reducing work absenteeism and cost of care, especially for those with the highest risk for disability31,32 (Case Vignette 42.1).
Table 42.1. SBST Classification of LBP
Few obstacles to recovery
Physical Obstacles to recovery
Low risk approach +
Psychological obstacles to recovery
A 49-year-old female previously diagnosed with fibromyalgia, type II diabetes, Raynaud’s disease, hypertension, rheumatoid arthritis, scleroderma, restrictive lung disease, and psoriasis, was referred to the Southern California University of Health Sciences clinic by her primary care physician for constant, 7–10/10 severity LBP with radiation to the left buttock and leg. The patient noted inability to drive, do housework, and go for a walk, and a desire to return to these functions. The patient had negative lumbar spine x-rays taken seven months prior. She was diagnosed with lumbar degenerative disc disease with radiculitis. The patient’s initial SBST score categorized her as high-risk for poor clinical outcome, she stated she had no confidence in her ability to overcome her problem, and was experiencing depression regarding her problem.
To address psychosocial aspects, a practitioner managing the patient might interweave cognitive behavior therapy; communicate using positive psychosocial messages; and/or apply tactics such as motivational interviewing along with self-care advice, exercise, and manual therapy. Such techniques can facilitate successful change management where psychosocial elements are the predominant features necessitating change, as well as improve prognosis for patients with moderate psychosocial and moderate to severe symptom severity and functional limitation. The degree to which a practitioner incorporates the psychosocial intervention is dependent on the SBST category in which a category 1 patient may simply receive reassurance and subtle tactics such as receiving active-care instruction prior to passive care (so as to experience the positive result of exercises without being able to attribute it to the passive care), whereas a category 3 patient may receive the gamut of psychosocial interventions. These techniques all necessitate a partnership between patient and practitioner such that the practitioner has an appreciation of the patient’s perspective, and, occur part and parcel with management of the “biological” aspect of the condition.
Perpetuating and complicating factors such as central sensitization, neuropathic pain, and even dietary impact on pain and inflammation are important considerations as well, but are beyond the scope of the written portion of this text. Figure 42.4S provides a graphic overview of perpetuating factors.
A Pathway Approach: An Emerging, Integrative Model for LBP
Failure of the biomedical model to yield improved outcomes for LBP has led to the creation of models attempting to recognize the reciprocal influences of cognitive, emotional, behavioral, and social/environmental factors, as well as biomedical or pathological factors. When considering the scope of human suffering and lack of clinical improvement in spite of vast economic costs, the conclusion of Deyo et al. must be taken seriously: “Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain. We must rethink chronic back pain at fundamental levels.”14
Dagenais, Caro, and Haldeman note that there is general agreement among the many published clinical practice guidelines (CPGs) for LBP assessment: (1) sequentially rule out serious spinal pathology; (2) find specific causes of low back pain; and (3) find substantial neurologic involvement.5 Haldeman et al. later describe general treatment possibilities for spine patients:
Evidence from CPGs suggests that management of spinal disorders should focus on patient education, advice to remain active, and short-term use of acetaminophen, non-steroidal antiinflammatory drugs, or spinal manipulative therapy to relieve symptoms. If symptoms persist beyond 6 weeks, the addition of therapeutic exercises, behavioural therapy or opioid analgesics can then be considered. A similar approach was recommended for spinal disorders with neurological involvement, although it may be necessary to consider epidural injections or decompression surgery if symptoms are incapacitating or fail to improve with more conservative care.7
Although the three diagnostic steps are necessary, the treatment recommendations that follow do not address the aforementioned supermarket approach; they do not inform the practitioner of the most efficacious management available. However, if we incorporate the principles discussed earlier—diagnosis-based treatment classification, psychosocial assessment and approaches, and prognostic categorization—we can formulate a comprehensive answer to the “what” aspect of the supermarket dilemma, and by following the pathway noted in Figure 42.5, it is possible to choose specific treatments, consultations, and/or collaborative care. It is beyond the scope of this publication to describe each clinical finding and corresponding specific treatment approaches and options such as end-range loading, manipulation, or strengthening exercises. Figure 42.6S provides an overview of diagnostic-based treatment guidelines in the setting of LBP.
Published practice guidelines discourage routine imaging and early, unwarranted interventional pain management;33 however, when clinically warranted, these are an important part of patient care. Figure 42.7S provides an example of institutional lumbar spine imaging guidelines
Although the pathway we have included lists treatments specifically targeted for various LBP presentations, it is important to note that these are listed because they have the greatest research validity, but they are in no way exhaustive lists of options and also do not dictate practitioner type. Patient preference and practitioner judgment must also be considered. For example, a patient with an acute radiculopathy may prefer to avoid NSAIDS and other medications and opt for pain relief with acupuncture and herbs. Myofascial therapy may be performed by any number of practitioner types including massage therapists, chiropractors, or physical therapists. A practitioner recommending home exercise should discuss options with the patient since one patient may prefer traditional physical therapy exercises, whereas another would prefer yoga and another pool-based therapy.
It is important to note that a guideline or pathway is not intended to prescribe a specific number of therapeutic interventions or a strict schedule of treatment. Any clinical decision, and in particular therapeutic intervention, should be made on the basis of documented improvement noted with periodic outcome measures that assess predetermined clinically meaningful improvement. Similarly, the decision to seek collaborative care, specialty consultation, diagnostic studies, or tertiary care should be made in the absence of such improvement (Case Resolution 42.1).
Based on her SBST scores, the patient received six chiropractic treatments over the next four weeks. Treatment modalities included cognitive behavior therapy, spinal manipulation, soft tissue mobilization, dietary modifications, at-home exercises, and activity modifications. By the end of the initial four-week period, the patient’s SBST classification decreased to medium risk, and she experienced moderate improvements in her ability to drive, do housework, and walk, as well as her confidence and depression levels.
Because of the patient’s multiple comorbidities, and her preference for herbal medicine, Oriental medicine treatment, which included acupuncture and herbs according to her Oriental medicine pattern differentiation, as well as cognitive behavioral therapy was introduced along with the chiropractic treatments. After four weeks of integrative treatment, the patient rated her pain as intermittent and 2–3 out of 10 in severity. She experienced further improvements in her ability to drive, do housework, and walk, as well as in her confidence and depression levels. Her initial and follow-up pain diagrams are noted in Figure 42.8S Her SBST score remained at moderate risk. The patient will require long-term supportive care but has achieved a higher level of self-efficacy and functional abilities.
Who Should Guide Patients Through the Pathway?
To effectively and efficiently manage LBP or any medical condition, professional resources and practitioner-mix must be aligned with the needs of the patient population. Porter described an emerging approach as the Integrated Practice Unit (IPU).34,35 Two of several important attributes of the IPU are that it be organized around the patient and provide the full cycle of care for a condition, including patient education, engagement, and follow-up; inpatient, outpatient, and rehabilitative care; as well as supporting services. In practical terms, following a pathway approach to integrative care of LBP does not require the formation of a formal IPU nor does it require that practitioners of all types be present under one roof. It is important, however, that consideration be given to a coordinated, resource-efficient, and collaborative effort among like-minded practitioners and administrators. Communication among members of an IPU can occur effectively in a variety of ways, usually utilizing methods such as reports, phone calls, grand rounds, case presentations, and team meetings. Assembling a multispecialty group by merely tearing down the walls of the silos is not sufficient to realize value and improved outcomes as noted in Figure 42.9.
Initial patient contact must be by practitioners capable of triaging the patient to the best-suited management pathway. Murphy et al., make the case for the establishment of a primary spine-care practitioner who is responsible for frontline diagnosis, management, and triage and who would help achieve meaningful goals of improved clinical outcomes at reduced per capita costs. This practitioner should have the skills and training to:
(1) Differentially diagnose serious pathology and know when and when not to order diagnostic tests and studies.
(2) Manage the majority of patients with spine pain without the need for referral.
(3) Explain the wide range of spine-pain disorders in a manner that patients can understand.
(4) Detect and incorporate management of psychological factors.
(5) Appreciate the concept of interventional minimalism.
(6) Understand the methods, techniques, and indications of intensive rehabilitation, interventional treatments, and surgical procedures in order to coordinate referral and follow up for patients who need secondary and tertiary level treatment.
(7) Be aware of public health in consideration of the many complicating factors, such as smoking, obesity, type II diabetes, lack of physical exercise, and mental health disorders, associated with LBP.
(8) Follow patients over the long term, with an emphasis on teaching patients how to effectively interpret and self-manage recurrences and provide further management when self-management is not effective.
Murphy, et al. and Erwin, et al., go on to state that chiropractic doctors are a good choice to act in this capacity;36,37 however, medical and osteopathic physicians and, depending on scope of practice legislation in varying jurisdictions, physical therapists and acupuncturists can fill this role, too. Above all, practitioner knowledge, abilities, and attitudes, not credentials, should be the primary consideration when selecting a primary spine practitioner. The key is having a designated person to guide care according to evidence-based best practices as captured by the care pathway. Patient outcomes should be collected and analyzed and the care pathway and implementation practices updated as better evidence becomes available.
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