Pathoanatomic diagnostic classification of low back pain is common despite there being mounting evidence it is harmful to patients and provides little clinical utility in 90-95% of LBP cases. The natural recovery trajectory of LBP is favorable. There are known psychological comorbidities that elevate risk of persistent pain and prolonged recovery; fear and castastrophisizng. The American Physical Therapy Association advises against focusing on pathoanatomy during patient education. Primary care guidelines do not recommend imaging unless serious pathology is suspected in the early stages of LBP. Prevalence of asymptomatic degenerative changes in the spine is >50% for most adults. Nearly half of back education classes taught in northern California focus on pathoanatomy as potential pain sources and patients walk away from primary care doctors office visits hearing they have arthritis intheir backs at alarming rates. Pathoanatotomic diagnosis may induce fear and catastrophisizing in patients with LBP which may elevate their risk of chronic LBP.
This is an interesting clinical concern: I spend a large amount of my clinic time with a rheumatology expert and feel like he has given similar informal talks about this topic in the past.
It's certainly a concern about spreading unnecessary worry to patients presenting with LBP that would otherwise resolve spontaneously without complication. Does the favorable projection you mentioned hold across age ranges? Also I was wondering about the >50% asymptomatic degenerative changes you mentioned. Is there no correlation between such changes and complaint of LBP?
Thanks for reply. That's a great question regarding age relationship to natural recovery. The favorable recovery idea comes from small to 0 beween group changes pain/disability/qol after some RCTs - I am going to dig if there is an age correlation there. curious
Regarding 'pain' associated with DDD - I believe clinically someone can 'flare up' DDD however there are many assymptomatic DDDs as I said and presumably inflammatory sx can come/go. There are risk factors but evidence on this is inconsistent- BMI, sex, occupation, smoking, inactivity and psychosocial issues are well established. Risk factors , as I understand them are more predicting or associating with pain rather than pain with DDD, however I think it is difficult to tease that apart? ADding the prevalence article as FYI
Brinjikji et al performed a systematic review which eventually included 33 articles reporting on MRI and CT findings for 3110 asymptomatic individuals meeting the inclusion criteria. Findings showed that the prevalence of disk degeneration in ASYMPTOMATIC individuals increased with age
Disk degeneration - 37% of 20-year-old to 96% of 80-year-old individuals.
Disk bulge prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age.
Annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.
Brinjiki W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imagingThis is a very relevant topic since low back pain is one of the most common complaints in primary care. I have seen many patients come back to clinic from physical therapy asking for an MRI because they were told they need it. Most providers usually give reassurance that there are no signs of a serious condition but some others order the MRI. It would be important to know how much imagining studies have been over-utilized? is there any evidence for a better diagnostic classification?
I am looking forward to hearing more about your project.
I am so glad we have someone addressing lower back pain. So, this sounds like a deimplementation problem - you want people to stop doing pathoanatomical diagnoses. Can you say something about the cost/harms of this unnecessary practice? Then we will get into how to dissect why it existis.
This is a deimplementation problem! I am currently aggregating harm/cost evidence. Looking forward to learning how to dissect this idea.
There is evidence that positive messaging to patients about back pain/natural recovery, focusing on inherent strength of spine, encouraging restoration of natural movement (and avoiding telling people NOT to move/promoting fear) and teaching pain science improves outcomes. Clinical guidelines recommend this however many PTs don't do this. Perhaps I may switch gears and focus on this?
Thank you for getting wheels turning on this!
Thanks for reply. Indeed patients/PTs ask for MRIs... How far do you go to 'please' your patient vs. make cost-effective decisions. Elvin brought up a great suggestion to look in to the costs associated with inappropriate diagnostic imaging and potential harm sequela associated.
There have been many classification systems proposed - however I do not think any of them have wide acceptance across all steakholders, mainly due to efficacy. START backtool might help to identify at-risk patients for disability, however recent studies as I understand them do not show consistent stratification. There are exercise/treatement based classification in the PT world (im a PT) that don't have strong enough study design (i think moderators were not properly evaluated) and are helpful in the clinic but still lack completeness.
I think the medical world over-all is doing less diagnostic imaging vs 5-10 years ago which is good however messaging to patients about findings within imaging is the question...