Pain in the Back: When is health care treatment too much?

Our health care system is great at many things – like developing innovative ways of treating and managing illness. However, we often don’t know when enough is enough. Low back pain is a prime example of a health care topic that often has too much treatment but that is very common. Almost 80% of us will have some low back pain at some point in our lives.[1]

We are lucky to live in state that has so much innovation – we are home to the game changers Microsoft and Amazon – and a state where so many top notch hospitals, health systems, and research institutions are dedicated to making us healthier and live longer, better lives. Luckily, we also live in a state that knows that too much care can be as big a problem as too little care and that when care varies from doctor to doctor and hospital to hospital this is a problem. The Bree Collaborative was formed to look at health care areas like low back pain where too much care can lead to bad outcomes for patients and where treatment is inconsistent. We all deserve to get the best care, and we also deserve to get the right, most appropriate care, no matter where in Washington we live.

Right now, about 20-30% of us have low back pain¹ but if you were go to your doctor, you might receive care that is not appropriate and might even be harmful. You might receive an MRI, be prescribed opioids, or be recommended to receive a spinal injection. Your low back pain treatment may depend on where you go for care, what their usual practice is, and not necessarily the type of treatment that suits your situation best.

Bree Collaborative members choose to look at low back pain and the best ways to treat it because of the high number of people with symptoms and the fact that employers seemed to be paying a lot of money for care that was not making employees better, and often made them worse.

After examining the evidence and convening a group of experts, our Collaborative decided to focus on three main areas:

1. Translating evidence-based guidelines into practice

We chose to recommend the American College of Physicians and the American Pain Society 2007 joint clinical guideline for primary care practices. This guideline was developed by experts and vetted by many organizations dedicated to making sure health care is high quality. We also want to be sure that your doctor is tracking whether you are feeling better or worse through the Oswestry Disability Index, a questionnaire that asks you to rate how severe your pain is and how it affects your ability to do everyday tasks like getting dressed.

2. Matching patients to appropriate care through evidence-based screening tools

When you do go talk to your doctor about low back pain, it is important that you receive the best treatment for your individual symptoms. The STarT Back Screening Tool asks nine questions that can help determine your risk of developing persistent, disabling back pain. The Functional Recovery Questionnaire is used by our State’s Department of Labor and Industries. These two screening tools can put patients on the right track and determine what type of care is most likely to get you back on your feet.

3. Increasing awareness and expectations about what low back pain treatment can do through patient education

It is important to remember that you should talk to your health care provider if you have low back pain and are concerned. However, it is important to remember that low back pain is very common and that there may not be a magic bullet for acute pain.[2]

After a treatable disease has been ruled out, remember that if you need advice, get it. Common messages about low back pain include:

– Try simple pain relief.
– Ask your health care team for low-impact exercises.
– While exercise like walking may hurt, it will not usually cause harm.
– Engage in a program of progressive activity.
……– Staying active in most cases is good for your back.
– No further test or specific therapy is likely to help.
…… – X-rays rarely show the reason for back pain.
……– Back pain is rarely caused by any dangerous illness.
– Only a few people with back pain need surgery.

Would you like to learn more? Read our full Low Back Pain Report and Recommendations. If you would like to know more about how too much health care can be harmful, read Dr. Atul Gawande’s new article:  Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?

Ginny Weir, MPH
Program Director, Bree Collaborative

[1] Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med 2009;169(3):251-8.
[2] Deyo RA, Mirza SK, Terner JA, Martin BI. Overtreating chronic pain: time to back off? J Am Board Fam Med 2009;22:62-68.