Approximately 80 percent of U.S. adults experience low-back pain at some point in their lifetimes, and one-in-four report struggling with low-back pain within the last three months. Low-back pain is the most common cause of job-related disability and a leading contributor to lost work time. But treatment often is ineffective, costly, and even dangerous. UCLA Health has established an initiative designed to ensure a standard, evidence-based approach to managing back pain in primary-care settings. The initiative is being spearheaded by O. Kenrik Duru, MD, MSHS, associate professor of medicine at the David Geffen School of Medicine at UCLA.
This really goes beyond back pain. UCLA Health has moved toward patient-centered care that is value-based, and part of that involves improving communication and coordination among primary-care doctors and specialists. We want a system in which all health care providers know their role and everything moves seamlessly. Back pain is a good place to start with that.
For one thing, it’s very common, and it involves treatment by both primary-care providers and specialists. And we saw that our UCLA Spine Center was getting many referrals from primary-care physicians of patients who didn’t necessarily need to be seen by a specialist. Most acute-back-pain cases — not just the first-time cases but also the ones that flare up every so often — will get better on their own. For those patients, time is the best medicine, and referring them doesn’t make sense for the health system or for the patient, who has to take time off work, make a copayment and then is told to go home, rest and wait. So we wanted to communicate to patients and to their primary-care physicians that once the doctor has carefully screened you for more serious conditions, you don’t need a referral to a specialist right away. Our other concern is that patients should not be getting X-rays or MRIs on uncomplicated back pain in the first four-to-six weeks. It doesn’t help, and it often will turn up abnormalities that aren’t related to the back pain. These false positives can lead to unnecessary treatment that puts the patient at greater risk.
Yes, and unfortunately, in too many cases, patients end up going on opiates, which can lead to long-term addiction and other problems. So we do have to be careful about overtreatment. About 85 percent of patients with back pain who visit a primary-care doctor have “nonspecific” back pain, meaning that a cause is never found; an additional 10 percent have herniated discs or spinal stenosis, which may require treatment at some point but are not medical emergencies. Of patients with back pain who seek care, 70-to-90 percent improve within seven weeks with conservative treatment — rest in positions that relieve the back, pain relievers, etc.
When a patient goes to his or her primary-care doctor complaining of back pain, the doctor does a history and physical exam, initially looking to exclude serious causes. After ruling out anything serious, the doctor classifies the patient into one of four groups based on the type of back pain. The first type is back pain that becomes worse with flexion — bending forward. The second is back pain with standing or flexing shoulders back. The third is leg pain that’s constant, and the fourth is leg pain that is intermittent — it’s leg pain but we believe the cause is coming from the back pain. For each of those conditions, we have a handout that the doctor can give to the patient with specific positions and exercises for that particular type of pain. The doctors also are advised to give either an over-the-counter pain reliever to the patient, recommend heat and/or ice and then follow up in seven-to-10 days. At that point, if the patient isn’t getting better and is still in severe pain, he or she can be sent to a specialist, although in most cases, patients are somewhat better in that time. There is also an option to go to physical therapy. At the six-toeight- week point from the initial appointment, if the patient still is in significant pain, we ask the primary-care provider to order imaging along with the option to refer to physical medicine and rehabilitation, pain management, East-West Medicine for acupuncture if the patient chooses that, or to a chiropractor.
Our goal is to make routine what we believe are high-quality practices so that patients, primary-care providers and specialists all know what to expect, and everyone is working from the same page. By standardizing highquality practices, we are improving both the safety and the quality of care for patients.