Changing perspectives on back pain
Michael Daubs, MD, Board Certified Orthopedic Surgeon, Southwest Medical Associates
Southwest Medical, part of OptumCare, is one of Nevada’s largest multi-specialty medical groups. We’ve been caring for southern Nevadans since 1972. We have decades of experience and a drive to better our patients' lives.
By combining technology and information, we give our patients the right care in the right setting. We provide primary, specialty, urgent, senior, OB-GYN, pediatric and convenient care.
The formidable impact of back pain on patients, doctors and health care resources in the United States has, in recent years, brought it to the forefront of patient care discussions. Back pain afflicts an enormous number of adults, and its incidence continues to grow.1
Despite the hit back pain takes out of our resources, the disability with which it shackles our workforce, and the pain and suffering endured by those who work daily to cope with it, for the majority of pain, we have not yet come upon an effective treatment for all patients.
Surgical vs. non-surgical outcomes
There are patients whose conditions make them excellent candidates for surgery to alleviate pain and disability. However, this is not true for all back pain.
Clinical outcomes (described as only sporadic pain, slightly restricted function, and occasional use of analgesics) are seen in slightly less than half of all post-surgical patients; radicular pain shows moderate improvement with surgery over alternatives.2
Also of note, patients who did not undergo surgery report improvement similar improvement to those who did over the course of one to two years.3
Non-surgical interventions such as cognitive behavioral therapy (CBT), physical rehabilitation, massage and yoga, put forth moderate evidence as effective for management of back pain.4
Implementation and availability of clinicians to deploy these often more effective and less expensive alternatives, however, evades us.
Back pain: a chronic disease
It seems wise to take a broad view of our expansive back pain problem. While continuing to seek out a remedy or “cure” for the epidemic, at this moment we have access to care delivery models that can better serve our patients and best use our not inexhaustible health care resources.
This first requires a perspective shift: in America, back pain must be acknowledged as a chronic disease.
Back pain may not threaten life through a direct pathophysiology, but it is still in league with major causes of morbidity and mortality. Pain leads to distress5 and disability threatening loss of livelihood, depression and anxiety.
Particularly when pain is chronic, the associated use of opioids puts patients at risk of dependence, addiction and death.6
Best practice care delivery for the chronic diseases that Americans cope with is instructive: diabetes, heart disease, kidney disease and respiratory diseases all demand coordinated, collaborative care.
The benefits of a collaborative model, the scope of the back pain epidemic, and the need for immediate management of back pain as it is a clear threat to health and life lead providers to the conclusion that comprehensive back pain management centers are the strategy to best serve patients.
A model for success
Within a successful patient-centric model, care is coordinated under one roof, literal or metaphorical, allowing for example a patient with back pain to receive speedy access to treatment with the best practitioners for their case.
Prompt attention from primary care, orthopedics, physical therapy and psycho-therapy improves care and decreases patient anxiety. Collaborative action to ensure pain is cared for reassures patients at this critical time.
Within a back pain care center, along with spine specialists able to evaluate and select the group of patients who would benefit from surgical care, one should find primary care, psychotherapeutic care (CBT), physiology, evidence-based pain management modalities, such as acupuncture, massage and mindfulness, along with orthopedic specialists.
This arrangement allows for tailoring a specific treatment plan to each patient’s needs.
With resources and support in place, patients will receive holistic, multimodal care, giving them the strongest chance to achieve optimal clinical outcomes. Based on these strategies, patients whose conditions are good fits for surgery can receive surgical care.
For those who would not respond best to surgery, alternative treatment can be more precise, less expensive and cause less disability.
A better view to what back pain is — a symptom to be managed with the help of your care team, not a disease that will cause financial hardship, pain and prevent fulfillment in career and life, provides a better vision for back pain care.
This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice.
1Shmagel A, Foley R, Ibrahim H. Epidemiology of Chronic Low Back Pain in US Adults: Data From the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Care & Research. 2016;68(11):1688-1694. doi:10.1002/acr.22890.
2Chou, R., Baisden, J., Carragee, E. J., Resnick, D. K., Shaffer, W. O., & Loeser, J. D. (2009). Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine, 34(10), 1094-1109.
4Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Winter C, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Comparative Effectiveness Review No. 209. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No 18-EHC013-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
5Daubs, M. D., Patel, A. A., Willick, S. E., Kendall, R. W., Hansen, P., Petron, D. J., & Brodke, D. S. (2010). Clinical impression versus standardized questionnaire: the spinal surgeon’s ability to assess psychological distress. JBJS, 92(18), 2878-2883.
6Phillips, J. K., Ford, M. A., Bonnie, R. J., & National Academies of Sciences, Engineering, and Medicine. (2017). Pain Management and the Intersection of Pain and Opioid Use Disorder.