Quality Assurance: The Scope of the Spine Problem and Modern Attempts to Manage It

Tim L. Raven

Lise R. Lothe

Craig Liebenson

LEARNING OBJECTIVES

After reading this chapter, you should be able to:

Understand the scope and course of spinal disorders.
Understand the risk factors for both acute and chronic low back pain.
Understand the benefits and limitations of common treatments for spinal pain.
Understand the benefits and limitations of management guidelines for low back pain and whiplash-associated disorders.

“ Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.

–MARIE CURIE

Introduction

In the past 20 years, specialists have seen tremendous changes in the management of spinal disorders. Low back pain (LBP) is the most commonly researched spinal condition. The LBP problem is acknowledged as an epidemic, and the position of LBP as a major cause of disability has been highlighted.¹ A consensus has gradually emerged as to why spinal pain has emerged as such a significant health problem and what can be done about it.²^,³ An overemphasis on the simplistic biomedical approach of identifying and treating the structural cause of pain has led to excesses in diagnostic testing,⁴ bed rest, narcotic analgesics,⁵ and surgery.⁶^,⁷^,⁸ Meanwhile, an underemphasis on illness behavior has led to an underuse of functional (reactivation advice, manipulation, and exercise) and cognitive-behavioral approaches.⁹ The ever-increasing impact of LBP on society—as illustrated by the Global Burden of Disease study¹—and a wide variation in practice habits—not necessarily justified by evidence of effectiveness—have been major motivations for the development and production of guidelines.

Patients with acute spinal problems tend to improve quickly, although typically resulting in neither complete recovery nor constant pain.¹⁰ Those who have chronic, persistent pain or become disabled are often failed by a health care system that characteristically falls into the trap of overemphasizing the structural cause of pain rather than providing reassurance at an early stage that there is no serious disease and that the road to recovery is through gradually resuming normal activities and restoring function.¹¹^,¹²^,¹³ Unfortunately, implementation of guidelines summarizing this modern self-management approach has been poor, despite the use of a variety of guideline implementation strategies.¹⁴^,¹⁵^,¹⁶^,¹⁷ Clinicians’ lack of content knowledge, methodological understanding, and trust in guideline development was found in a systematic review to be major barriers to the implementation of LBP guidelines.¹⁸ Rather than trying to achieve implementation of guidelines directly via the practitioner, it may be easier to educate patients who then will influence physician behavior.¹⁴^,¹⁹

Acute LBP is one of the foremost symptoms that leads an individual to seek health care services.²⁰ From diagnostic triage to rehabilitation, the modern goal of care is to maintain or resume normal functional activities.⁸^,²¹ Certain benchmark “tools of the trade” include diagnostic triage (without imaging unless “red flags” of serious disease are present), appropriate referral if there are “red flags,” or reassurance that there is nothing serious, simple reactivation advice, and pain relief options such as medication (usually over-the-counter) and spinal manipulation.²²^,²³

The subacute patient has reached a different decision point. Beginning at the 4-week mark, a patient who has not significantly improved is “de facto” at increased risk for chronicity and thus requires a different “tool set.”⁹ Structural (i.e., imaging), functional (physical performance ability), and psychosocial reevaluation is necessitated.⁸^,²⁴ This may include cognitive-behavioral education or exercise (i.e., McKenzie, stabilization, or isotonic), with no particular approach clearly shown to be superior to any other at present.²³ Recent research has reinforced that it may not be so important exactly what is offered so long as it is matched to patients’ activities and preferences, and offered with worksite involvement if related to occupation.⁶^,²⁵^,²⁶ Certainly, so long as appropriate indications—progressive neurologic deficit or significant nonresponsive leg symptoms and confirmatory imaging findings—are present, spinal surgery is an option at this stage.²⁷

A key question remains as to who should receive which components of this “benchmark” and when. Generally, too much care is withheld until patients have well-established chronic pain syndromes when costs are extremely high and effectiveness is low.⁸^,²⁸^,²⁹^,³⁰. An extensive work by the Keele group, building on many years of work by others, has demonstrated the value of stratifying individuals into groups with targeted treatment based on risk of chronicity so that appropriate care is delivered to those who need it the most.⁶^,¹²^,³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷ The identification of psychosocial “yellow flags” indicative of a decreased likelihood of recovery has been proposed as a technique for early identification and thus matched with appropriate management of those with a poorer prognosis.²⁷^,³⁵^,³⁸

Scope of the Problem

Incidence

Acute LBP affects most of the population at some time or another. By the age of 30, nearly one-half of the population will have experienced a significant episode of LBP.³⁹

Approximately 25% of the population will experience first-time LBP or transition from pain-free to pain state in the space of a year, regardless of whether in community or occupational populations.⁴⁰ The prevalence of LBP varies widely from 5% to 65% depending on the country involved and the methodology of the
researchers⁴¹ and constitutes the largest cause of years lived with a disability. In a global context, LBP causes more global disability than any other condition.¹^,⁴² Hoy et al⁴² estimate the point prevalence for LBP to be 9.4% and neck pain to be 4.9%. LBP is more prevalent in men than in women, whereas neck pain is more common among women. The lifetime prevalence rate (chances of having LBP in one’s lifetime) has been estimated at 70%.⁴³ Similarly, European studies have demonstrated 1-year prevalence rates of 35% to 40% and lifetime prevalence rates of between 60% and 80%.¹^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹^,⁵⁰

Those with a history of previous LBP have up to twice the rate of new episodes compared with those with no LBP in the past. Subjects with more than 30 days of LBP the previous year have an increased risk of developing long-term LBP. Forty percent of people with LBP for more than 30 days at baseline remained in that group 1 and 5 years later, whereas 9% with LBP for more than 30 days in year 0 were pain-free in year 5. Neck pain or pain in other musculoskeletal sites at baseline also doubled the risk of a subsequent new episode of LBP.⁴⁸^,⁵¹ Unfortunately, even though the chronic problem affects a small percentage of individuals, it consumes the majority of the costs associated with this problem.⁵²

Course of LBP

It has been traditionally taught that acute LBP episodes resolve within weeks. This is based on insurance surveillance data that mostly tracked disability. The assumption of such an excellent natural history led to the mistaken belief that acute LBP could be managed symptomatically (bed rest and medication) and left alone. However, there are two problems with this perspective. First, the view that most acute episodes resolve quickly and completely is disputed by a number of studies of primary care patients.⁵³ Second, there is a growing body of evidence that not only doesn’t LBP necessarily resolve as quickly as previously thought, it is now clear that patients with LBP and neck pain have distinct clinical course patterns.¹⁰^,⁵⁴^,⁵⁵ Finally, it is more cost-effective to attempt to prevent chronicity in those at risk for it rather than waiting to treat only those in whom it becomes fully apparent.⁸^,³⁰^,³⁶^,³⁸^,⁵⁶^,⁵⁷

One of the first studies that cast doubt on the often suggested rosy natural history for LBP was by Lloyd and Troup who presented evidence that showed that 70% of people continued to have residual symptoms even after they returned to work.⁵⁸ Similarly, Butler et al demonstrated that even though most disabled workers with LBP return to work within 1 month, 50% of them relapse within 1 year.⁵⁹ Von Korff et al demonstrated in a nonoccupational setting that after 1 month only 30% of neck pain and LBP patients had achieved pain-free status, and after 1 year, one-half still reported recurrent or persistent pain.⁶⁰ Although this study is often criticized for not exclusively limiting itself to patients having their first ever episode of acute LBP, it nonetheless served as a wake-up call that the presumed natural history of LBP episodes was not what “experts” claimed. In fact, it could be said that because most of our acute patients have had symptoms before, Von Korff et al’s study is a more realistic look at the natural history clinicians in the trenches actually see.

Henschke et al followed the progress over 1 year of almost 1,000 LBP patients recruited from primary care in Australia.⁶¹ Subjects included both first-time back pain sufferers and those with a previous history, although the current episode had to be less than 14 days duration. The authors noted that recovery was slow for most patients and that at 1 year almost one-third of patients had not recovered. This certainly did not equate with the traditional belief of early and natural recovery. Although 83% of subjects had returned to previous work status at 3 months, median recovery time for disability was 31 days and median recovery for pain was 58 days. A recent meta-analysis demonstrated that pain improved rapidly, but disability improved more slowly in acute and persistent LBP cases.⁶²

Croft et al performed a prospective study with an inception cohort of 463 adults presenting to general practitioner (GP) in England.⁵³ These were patients having their first consultation for LBP in the past year. They could have had LBP, but not any consultations, within 1 year. The criteria for recovery were reduced pain and disability. At 3 months, although 91% stopped consulting, only 21% had completely recovered. At 1 year, only 25% had completely recovered.

The traditional view that most LBP patients recover in 4 to 6 weeks is not supported by the current literature (Table 2.1). Croft et al summarize current thinking as, “The findings of our study are in sharp contrast to the frequently repeated assumption that 90% of episodes of low back pain seen in primary care will have resolved within a month.”⁵³

Several studies suggest that the 1-year data indicate a significant unrecognized problem.⁵³^,⁶³^,⁶⁴ Croft et al say, “We should stop characterizing LBP as acute problems which recover, but rather as a chronic problem with frequent recurrences.” Most striking is Croft et al’s conclusion that more aggressive early treatment may be needed to address this rather nonbenign natural history: “Since most consulters continue to have
long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact.”

Table 2.1 Summary of the Natural History for LBP

The good news

For the majority, improvement begins rapidly.
Chronic, unremitting LBP affects a minority of patients.
Disability persists in a relatively small percentage of individuals, even in those with chronic LBP.
Most individuals don’t seek care, and when they do it, it does not last long.
Satisfaction with chiropractic care is very good.
The economic costs for managing most LBP is not that great.

The bad news

Complete resolution of symptoms and activity intolerances does not occur rapidly.
The recurrence rate is high.
Satisfaction with medical care is not very good.
The economic costs related to the small minority of individuals with persistent, disabling occupational LBP are an enormous problem for society.

LBP, low back pain.

Inherent problems of recall bias have undermined the strength of conclusions based on studies that utilize follow-up data at long intervals. To overcome this problem, recent studies have utilized weekly measurements of pain intensity and frequency via SMS tracking.¹⁰ This innovative technique has provided valuable information on the pain trajectories of LBP sufferers. In the case of LBP, diagnostic information usually does not tell much about probable future outcomes because only in a minority of cases can a specific pathoanatomic diagnosis be reached. The majority of LBP is categorized as nonspecific LBP and therefore may be better understood and managed within a prognostic framework. Making use of a prognostic model for LBP allows us to categorize LBP patients into a number of subgroups based on trajectories (Fig. 2.1).⁶⁵ Although it is intuitively useful to be aware that patients will exhibit a variety of clinical trajectories, the clinical utility of subgroups based on prognostic modeling is at present unclear.

Deyo and Weinstein agree saying, “… the emerging picture is that of a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured.”⁶⁶ Dutch findings confirm this by detecting that at 12 months after initial consultation, even though only 10% of patients still had the same episode (chronic patients), 75% had reported at least one recurrence.⁶⁷ Unfortunately, recent literature concerning the causality of LBP does not differentiate between the “disease” of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, it is difficult to determine causality based on current research.⁶⁸

The Broader Health Consequences of LBP

We shouldn’t underestimate the association between spinal pain and other disease processes. It is generally recognized that musculoskeletal pain, in particular spinal pain, is closely associated with increased disability and poorer quality of life. People who report chronic widespread pain subsequently consult more frequently about nonmusculoskeletal and musculoskeletal problems than people with no pain, and this is not explained by psychological distress.⁶⁹ Among older Australian women, diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain.⁷⁰ Older people reporting spinal pain have 13% increased risk of mortality per year lived. However, this association is not likely to be causal, with the relevant confounders contributing to this relationship. Thus, pain in the spine may be part of a pattern of poor health, which increases mortality risk in the older population.⁷¹ Importantly, decreased physical inactivity itself often plays an independent role as a direct cause of speeding the losses of cardiovascular and strength fitness, shortening of health span, and lowering of the age for the onset of the first chronic disease, which, in turn, decreases quality of life, increases health care costs, and accelerates mortality risk.⁷² Other lifestyle choices appear to be associated with LBP, although a causal link has not been demonstrated.⁷³ The modern spine practitioner should be assessing the entire person who presents with spinal pain, taking into account the total health status of the patient and managing all conditions as appropriate in collaboration with other health care professionals.

How Can Physicians Decide if LBP Has a Serious Cause?

Nonspecific LBP—where a specific pathoanatomic diagnosis is not possible—accounts for about 90% of all LBP seen in primary care.⁷⁴ Red flags are common yet rarely indicate serious spinal pathology. In a longitudinal cohort study in primary care settings in Australia (n = 1,172), less than 1% of patients were found to have a serious cause for their LBP (e.g., cancer, infection, or fracture), despite 80% of subjects having at least one red flag. Night pain is a commonly cited red

flag, suggesting the need for further imaging; however, such a finding is extremely common. In a prospective longitudinal study involving 482 consecutive patients attending a back pain triage clinic, 213 (44%) reported night pain; yet, none of these patients had serious disease.⁷⁵ The only red flag for malignancies to provide adequate diagnostic reliability in LBP is having a history of previous cancer.⁷⁶^,⁷⁷ The concerns of more serious illness that often bother patients with spinal pain influence their expectations, with many spinal pain patients expecting diagnostic imaging.⁷⁸ This presents clear challenges for the clinician in explaining why imaging may not be appropriate and may be a barrier to implementation of guidelines.

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