Primary Care for Low Back Pain: We Don’t Know the Half of It

Author: Frank M. Painter

Evidence-based medicine helps health care professionals and patients decide best care, drawing on research about effectiveness and safety of interventions. Systematic reviews summarise the evidence; guidelines report consensus between experts (including patients) on interpreting it for everyday practice. Although guideline recommendations are only one component of shared decisions that will vary patient-to-patient, the hoped-for outcome is health benefit for each individual. Guidelines also inform starker decisions by policymakers and health care leaders — for example, when to withdraw approval or funding for a poorly evidenced or harmful intervention. To assess whether all this research-driven activity is useful, 2 questions need answering: how well are guidelines followed in real-life practice and do patients benefit in the long-term?

In a new systematic review, Kamper et al. tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, and there is good evidence for what constitutes best first-contact treatment. The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit).

These findings are not entirely unexpected nor, as the authors point out, should blame be placed entirely at the door of front-line physicians. Qualitative studies reveal family practitioners agreeing with guideline conclusions but frustrated in implementing them by factors such as patients with complex needs or lack of resources for behavioural interventions and rehabilitation.

Furthermore, physicians will point to the nuances of individual patients who do not neatly fit the template for guideline recommendations. The review’s authors acknowledge this when discussing the difficulty of measuring “appropriateness” of physician requests for imaging.

The review did not study nonphysician primary care providers. Many such practitioners deliver care aligned with guidelines, such as advice about activity and exercise. More allocation of first-contact low back pain care to professionals such as physical therapists [AND chiropractors] could help to address the problem of inappropriate care. However, although some back care, such as imaging requests by physical therapists, may be more guideline-concordant, a recent systematic review indicated physical therapists have low adherence generally to guidelines for musculoskeletal pain, and a comparison of nurse practitioners and physicians in primary care revealed similar rates of unnecessary imaging requests.

It is increasingly clear that simply expecting individual clinicians to adhere more closely to guidelines is not going to close the evidence-practice gap. Recent articles have argued that effective “high-value” care for patients with low back pain (“benefit more likely than harm”) will only be achieved through large-scale top-down changes across health and social systems (“system strengthening”).

Such changes include engaging policymakers, politicians, and profession leaders to change laws and reimbursement practices; addressing counterproductive commercial pressures; creating incentives for optimal care; providing adequate resources for delivery of guideline care (including digital innovation); shifting professional education and training toward high-value care, including nonpharmacological approaches; dissolving boundaries between health care professions to create unified programmes of care; and changing culture and pain literacy among patients and populations to encourage prevention and positive health activity. The success of such innovations, however, cannot be taken for granted and will need evidence that they bring long-term patient benefit.

There is a second important issue highlighted by the authors of the review — the scarcity of relevant information to answer their question “how well are back pain guidelines implemented?” The review focused on studies reporting actual clinical care because it was recorded in health care or insurance databases. A challenge for data collection systems, particularly in family practice and emergency departments, is how to ensure such records include all aspects of care. Prescription medicines, imaging requests, and referrals to other services tend to be routinely recorded, whereas the nature and detail of patient assessment, and the content of advice and information given, often go unrecorded. Absence of data may mean either care has not been delivered — or it has been delivered but not recorded. Thirty years after randomised controlled trials reassured patients that an average low back pain episode did not require a week in bed, there is no high-quality data on what primary care physicians have been advising about bed rest.

This absence of information about relevant areas of the primary care consultation should concern us as much as the size of the evidence-practice gap or how to close it. Having the right information will itself help change policy and training and behaviour about guideline treatments, for example, by easing the path to audit as a means to improve practice. The “finely grained” information the review calls for (such as linking prescription records with the indications for prescribing) would address concerns that health care databases do not currently convey all the nuances of decision-making — not all imaging requests are wrong, not all opioid prescriptions are wrong-headed.

The authors of the review could find no high-quality studies using actual practice data from first-contact low back pain care in low- and middle-income countries (LMICs). This is of particular concern because LMIC populations are being exposed to technology and treatments for low back pain (such as opioids) that high-income countries have popularised and made profitable but that are often inappropriate and harmful. Low- and middle-income countries need appropriately strong systems to support delivery of high-value care, including guideline-concordant approaches to low back pain prevention and care that align with local practices and cultures of health and wellbeing. Achieving data collection systems and routine analysis to document low back care is a plausible investment target for LMIC populations such as Nepal that are digitally equipped even when geographically remote11 but will be hindered while pain research has no priority and remains focused on low-value items of care.

It is a strange situation to contemplate. In an information-dominated world where people’s purchasing actions are instantly known, retrievable, linked to other data, and acted upon, the [medical or “usual”] care that most people are receiving for the world’s leading cause of long-term disability is not known because it is either not recorded or the data are not accessible or reported. The challenge to digital science and modern informatics is how to record and retrieve this information without overloading already busy clinicians or saturating patients with data collection. But, along with the challenges and the risks, there is the potential for new technology to change and improve delivery of health care globally for conditions such as back pain.

The case revealed by Kamper et al. for having more accessible, better organised, well-resourced, easily collectable information about the daily content and outcomes of consultations for this most common of disabling pain conditions is clear. The international pain community, in collaboration with health care data scientists, should get behind it.

Are You Well?

Wellness refers to the condition of good physical and mental health, especially when maintained by proper diet, exercise, and habits. Nutrition refers to the nurturing of our body, in our ability to keep it healthy and functioning as it is supposed to do. Our ability to provide the body with all the necessary food, vitamins, and minerals so that we continue to thrive in our daily life processes. But do we know if we are really well? How do we tell?

The first place to start would be with the examination of your eating habits. Since we are a product of what we eat, if our eating habits are unhealthy, or do not provide for the nutrition we need, we’re not going to be healthy individuals at the end of the process. Do you take in more calories than your body needs? Are you supplementing your vitamins and minerals to make sure you are getting your recommended daily allowances? If you’re not making the most basic of efforts to take care of your nutritional needs, you aren’t a well individual. You may not look sick, you may not have any noticeable symptoms of ill-health, but you’re not the well individual you could be.

Next, you might want to look at your exercise habits, if there are any. If there aren’t any exercise routines to examine, no wellness. Everyone, no matter what their age, benefits from exercise. It keeps our bodies conditioned, our mental sharpness working at top speed, and thanks to the physical aspect, we get a boost to our cardio health, extra calorie burn, and more oxygen to those cells!

What about the stress levels in your life? Do work in an environment with high levels of stress? Is your personal life a source of comfort or does it add to your stress levels? Do you engage in some form of stress-relieving activity? Stress is the number on contributor to heart attacks and strokes, since they manage to speed up the affect of the real culprits. Stress is basically an out of control situation for most adults today. We manage to schedule every moment of our free time, and leave ourselves with no time for quiet reflection, or time to deal with life’s unexpected emergencies.

Stress brings us to the next two topics of health abuse. Smoking and drinking are often used to offset the effect that stress has on our nervous system. These solutions however do not provide any real help. If you smoke, drink, or lose sleep to excess, you’re not the well individual you could be. Smoking, drinking, and loss of sleep work to our detriment, and it takes extreme discipline to stop. Smoking fills our body with carcinogens, and works to keep us tired and lethargic.

There are so many occasions to stop and question our efforts at maintaining optimal health, that we usually don’t even take the time to begin the examination. But it is beneficial to our overall health, the quality and quantity of our life, to make every effort to be well, healthy, individuals.

Acupuncture Could Help You Finally Manage Your Stress Levels

Today’s world can fill the very busy individual with a lot of stress. Without some way of removing this stress from your system, you’re placing yourself in danger from a lot of stress-related diseases. You might suffer from insomnia or headaches or very serious heart diseases.

You could take anti-stress pills to help you relax but, like me, you might also be worried about the side effects these pills could have. The good news is that you could try acupuncture at least once to see if it could help you manage the stress. It certainly couldn’t hurt to try acupuncture if all you’re after is stress relief.

If you find it doesn’t work for you, then you can just easily stop taking acupuncture treatments. If it works, though, then you can say you’ve found a good treatment for stress that doesn’t rely on those dangerous chemicals and pills.

How does sticking needles into your body help manage the stress?

In traditional Chinese medicine, much of the treatments depend on an understanding of the balance in our bodies and its internal organs. The sicknesses we sometimes develop are seen to be caused by imbalances in our lifestyles and environment. Stress is also affected by this imbalance. That is why when there is something wrong with your body, you’d typically have less of an ability to deal with stress. You’d get more irritable and find it really to difficult to relax.

By sticking these very thin needles past the surface of our skin, the acupuncturist stimulates nerves in our body. These nerves send signals to our brain and scientists believe that the brain then releases its natural painkillers into our system. This immediately causes a feeling of relaxation for many people.

The needles could also help your body by stimulating its circulation. With the circulation between the organs of the body improved, a lot of the body’s wastes could be cleansed properly. Your organs would also receive the full benefit of the oxygen from your lungs making its way into the cells of your body without any blockages. This makes your organs much healthier and leaves you feeling much better in the long term as well.

You can think of a session with the acupuncturist as very much like massage therapy. A good massage would help give you a very relaxing sleep that night and an acupuncturist could help you with your sleep as well. You might immediately start to feel drowsy as soon as the right nerves are stimulated by the acupuncturist’s needles.

You might be asking yourself how you’d be able to relax if you’re suffering from the pain of the needles attached to your body. What you might not realize is that because of the thinness of the needles, you would hardly feel anything. The most that many people claim they feel is a kind of tingling feeling where the needles are. And that is actually a sign that the process is working,

Acupuncture is a practice that helps you use your bodies’ own ability to manage stress properly. This leaves you healthier, and more importantly, prevents any of the serious diseases that could come from unbalanced, stressful lifestyles.

It might not be something to replace regular trips to the doctor but with its many possible benefits, acupuncture might be worth trying out very soon.

Eat A Wide Variety Of Foods For A Healthy Diet

One of the most frequently cited reasons that diets and attempts at healthy eating fail is boredom. Many people simply do not know how to keep a healthy diet interesting day after day, and it can be quite a challenge.

Given the huge variety of fruits, vegetables, whole grains, meats and other healthy foods at the local grocery store, however, it is definitely possible to create exciting, nutritious meals that will keep boredom at bay.

Your key to healthy eating
The key to the success of any plan for healthy eating is to eat what you like, but to exercise moderation when it comes to the less healthy foods. Improving your level of health and fitness does not mean forgoing that piece of chocolate cake, for instance. It does mean, however, limiting yourself to one piece. A healthy diet contains all types of foods, including carbohydrates, proteins, and even fats. The key is choosing foods that provide the best combination of taste and nutrition. After all, if your diet consists of foods you hate, you will not stick with it.

The revised USDA food pyramid contains five major food groups – grains, vegetables, fruits, milk and dairy, and meat and beans. When choosing foods from these groups, it is important to eat a wide variety of foods from every food group. Doing so will not only give you a great deal of variety and keep boredom from setting in, but it will provide the best nutritional balance as well. In addition the widely known micronutrients, such as vitamin A, vitamin D, vitamin C, etc. all foods contain a variety of macronutrients, like fats, proteins, fiber and water. Though present in extremely tiny amounts, micronutrients are vitally important to good health. That is why a healthy, varied diet is so important.

In addition, when choosing foods from within the various food groups, some choices are naturally better and healthier than others. For instance, choosing skim or 2% milk instead of full fat whole milk is a good way to cut down on both fat and calories. And choosing poultry or lean meat is a great way to get the protein you need every day without extra fat, cholesterol and calories.

Likewise cereals and breads that carry the whole grain label are healthier than those who do not. Even in the world of fruits and vegetables some choices are better than others. For instance, peaches packed in heavy syrup add unnecessary sugar to the diet, while those packed in water or juice provide only good nutrition.

There has been a trend lately to add vitamin fortification to food, and this can sometimes be a good way to maximize nutrition. It is important to remember, however, that proper nutrition comes from a healthy diet, not from vitamin supplements. It is fine to buy calcium fortified cereal, but the bulk of your calcium intake should still come from milk, dairy products and green leafy veggies.

Choosing the best foods
Knowing the five major food groups and how much of each to eat every day is only part of the picture. The other part is choosing the best foods from within those food groups. That means things like choosing the leanest cuts of meat, using egg substitutes instead of whole eggs, choosing the freshest fruits and vegetables, etc.

Even with fruits and vegetables, some choices are better than others. Some fruits, such as avocados, for instance, are packed with fat and calories. It is important to check the nutritional qualities of the fruits and vegetables you buy, and not simply assume that all fruits and vegetables are equally healthy.

One way to maximize nutrition while minimizing cost is to buy fruits and vegetables that are in season. Fruits and vegetables that are in season are usually quite a bit cheaper than those that must be shipped hundreds or even thousands of miles, and they are generally much fresher too. Of course, depending on where you live, there may be varieties of fruits and vegetables that are not available locally, so the northerner in search of citrus fruits will just have to watch the sales and buy accordingly.