Research Review Corner: September 2009

It is well known that low back pain (LBP) is a common and costly
condition. LBP patients often first consult with their family physician
(and then perhaps a specialist) in hopes of finding answers regarding
their pain and appropriate treatment suggestions.

Background Information:
It is well known that low back pain (LBP) is a common and costly
condition. LBP patients often first consult with their family physician
(and then perhaps a specialist) in hopes of finding answers regarding
their pain and appropriate treatment suggestions. In fact, back pain is
the most common musculoskeletal reason for consulting a family doctor.
It is therefore imperative that GPs have a high competence in managing
these patients.

This year, one of the most highly regarded spinal medicine journals
published two studies which, taken together, suggest that those who are
consulted first (in most cases) for LBP are not managing this condition
in an evidence-based manner. This includes family physicians,
orthopedic surgeons, and even those doctors with a reported “special
interest” in back pain. To borrow a line from the Canadian Chiropractic
Protective Association’s Dr. Greg Dunn…OUCH!!

As chiropractors, we hold a special level of knowledge about back pain,
and possess numerous treatment tools that can be useful in its
management. Currently, significant effort is being put forth to
position us as the “spinal care experts” in the Canadian health-care
system. With such a “title” comes great responsibility. While reading
the results of these two studies, readers should ask themselves how our
profession would fare in a similar study…

Study Descriptions and Results:
Study #1: Buchbinder et al.: Previous literature has suggested that general practitioners only
partially manage LBP in an evidence-based manner. Further, there is
existing literature to indicate that individual practitioner beliefs
direct their practice patterns. This study aimed to determine whether
GP beliefs about LBP management differed according to whether they had
a “special interest” in back pain, occupational, or musculoskeletal
medicine. Surveys were completed by 3,831 GPs in Australia (a response
rate of 38.2 per cent). Pertinent results follow:

• Compared to GPs with no special interest, those with a special
  interest in LBP were more likely to believe that complete bed rest
  (17.8 per cent versus 9.2 per cent) and work avoidance (24.5 per cent
  versus 15.8 per cent) are appropriate management approaches for acute
  LBP.
• Special interest GPs were also more likely to believe that lumbar
  radiographs are useful in the workup of acute LBP, and that their
  interventions were unlikely to have a positive impact on the natural
  history of acute LBP.
• GPs with a “special interest” and recent continuing education work
  had significantly better LBP management beliefs (but, this only
  equalized them with other GPs essentially) – they were less likely to
  prescribe complete bed rest or lumbar radiographs for acute LBP.
• The authors state: “Taken together, these results provide strong
  evidence that poorer beliefs about management of back pain is driven by
  a special interest in LBP. These findings raise serious concerns about
  how back pain is currently being managed among general practitioners
  with a special interest in LBP.”

Study #2: Finestone et al.: This was a comparative knowledge survey including GPs (n=140) and
orthopedic surgeons (n=253) from Israel. All participants completed a
questionnaire at an annual professional meeting that evaluated their
knowledge of managing simple LBP. Pertinent results follow:

• Response rates were 84 per cent for the surgeons and 45.3 per cent for the Gps.
• 53 per cent of surgeons incorrectly recommended treatment with
  cyclooxygenase-2 (COX-2) selective NSAIDs as their preferred treatment,
  versus only eight per cent of Gps.
• 67 per cent of surgeons and 46 per cent of GPs recommended some form of bed rest.
• Although both groups acknowledged the potential benefit of spinal
  manipulation, 51 per cent of surgeons and 57 per cent of GPs
  incorrectly suggested that it was appropriate in all cases of LBP.
• 29 per cent of GPs and 46 per cent of surgeons failed to rate patient explanation and encouragement as “extremely important.”
• 53 per cent of surgeons and eight per cent of GPs felt imaging was always necessary.
• Overall, seniority was not related to questionnaire scores, and
  surgeons performed significantly worse (roughly 25 per cent) than GPs
  (p<0.0001).

Conclusions and Practical Application:
The two studies summarized
above paint a disappointing picture of medical management of simple
LBP. The integration of some major evidence-based concepts (such as not
prescribing bed rest, the limited utility of imaging, and the broad
spectrum use of COX-2 NSAIDs) is severely lacking.

Further, it is particularly alarming that orthopedist knowledge
surrounding simple LBP is deficient, especially when one considers the
major risks and poor prognosis associated with their primary
intervention (surgery). Taken together, these results should provide a
strong wake-up call for medical practitioners and educators.

Rather than pointing a shameful finger at our medical colleagues,
chiropractors should seize this opportunity to review and update their
own knowledge on evidence-based management of LBP so we can continue to
provide top-notch care to our patients, and improve our growing
reputation among medical practitioners and patients as the spinal care
experts. •

Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners to integrate current, relevant scientific evidence into  their practice. Shawn graduated from CMCC and holds an Honours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medical Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Provider.  For more information about the Research Review Service, visit www.researchreviewservice.com .