Docs not backing published guidelines when treating spinal pain

Docs not backing published guidelines when treating spinal painPhoto used with permission from

According to a study published in the latest edition of JAMA Internal Medicine, physicians are partaking in a great deal of proverbial back talk when it comes to following back pain treatment guidelines.

Researchers from the Harvard School of Medicine in Boston scoured the results of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to examine how physicians were treating back pain on the basis of image ordering, physical therapy referrals and the prescribing of narcotic medications and other nonsteroidal anti-inflammatory drugs as well as acetaminophen.

As "back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines,” a definitive investigation into national treatment trends of this nature is not only needed to assure that quality care is being delivered but to identify areas where the industry can curb overspending, the study notes. 

Of the 23,918 visits made by patients with spine problems, the study team discovered the following trends:

  • Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9 percent in 1999-2000 to 24.5 percent in 2009-2010.
  • Narcotic use increased from 19.3 percent to 29.1 percent in the same timeframe.
  • Physical therapy referrals remained unchanged at about 20 percent.
  • Physician referrals increased from 6.8 percent to 14 percent.
  • The number of radiographs remained at about 17 percent, but the number of computed tomograms or magnetic resonance images increased from 7.2 percent to 11.3 percent during the study period.

"Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use and no change in physical therapy referrals. With healthcare costs soaring, improvements in the management of back pain represent an area of potential cost savings for the healthcare system while also improving the quality of care," the authors concluded.

In a complementary commentary, Donald E. Casey Jr., MD, went on to describe further the widening chasm between treatments and recommendations in the spinal realm: “Whereas these guidelines promote use of nonopioid analgesics, avoidance of imaging tests, use of physical therapy-based exercises, and primary care for this population, the results of this analysis demonstrate recent significant decreases for these recommendations. The first step in addressing a problem is to admit that you have it, and in that regard the article by Mafi et al forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain. It is only by achieving greater concordance on the evaluation of the efficacy of back pain interventions that we can achieve greater concordance on our practices."

The study was funded by a National Research Service Award training grant from the U.S. Health Services and Research Administration, the Ryoichi Sasakawa Fellowship Fund and a Harvard Catalyst National Institutes of Health Award.

Photo used with permission from