The Role of Educational Materials in Delivering Information to Patients

Welcome back to SpineIQ’s BackBlog! In previous blogs, we have discussed how educational materials can play a key role in delivering information to patients. Not only can these educational materials be used actively throughout a session to lead conversations with patients but they can be used to provide information “passively” as posters in your clinic that patients may read. Educational materials can play a key low-cost, low-time consuming role in care for low back pain.1 Especially as patient education is recommended consistently by clinical practice guidelines for spinal pain regardless of pain duration or intensity.2,3 However, what the best way to present this information has not been studied. The study we summarize in this blog sought to assess whether “fact sheets” or “myths and facts sheets” led to patients remembering the information better and led to a decrease in fear avoidance behavior.4

Aims and methods

Mass media campaigns have been used in public health campaigns for decades. Some of the more famous ones have been advertisements and commercials providing information about the dangers of tobacco. The research on the best way to present educational information has been conflicting. Some studies suggest that presenting “myths” may lead people to mistakenly remember the “myths” as “facts.”5 However, other studies suggest that presenting both “myths and facts” can provide a more persuasive argument than only “facts.”6 This study created two educational materials. One sheet with 6 facts written on it and another sheet with the same 6 myths plus 6 myths related to the facts. Participants were patients seeking care for chronic low back pain, who were randomized to either “facts only” or “myths and facts” sheets. The outcome measures were being able to correctly answer all 6 questions about the facts at their next visit and their score on the FABQ-pa, which measures their fear avoidance beliefs towards physical activity.

Results

151 patients were randomized into one of the two groups and subsequently analyzed. There was no difference in correctly answering 6 questions about the facts between the two groups. An average of 32% correctly answered all 6 questions in each group. The group that received “myths and facts” information sheet had statistically significant better fear avoidance beliefs at follow-up, however the difference was small and unlikely to be clinically meaningful.

Conclusion

These findings present a great opportunity for clinicians to feel comfortable that the educational material that they share with patients, social media, or have in their clinic can be presented in different ways. There appears to be no difference in patient recall, which suggests that presenting “myths” will not lead to patients mistakenly misremembering them as facts. At SpineIQ we provide several  back pain fact sheets on our website. There are also some facts and myths on low back pain sheets that have been used in the published literature, such as the ones used in this study and a study by O’Sullivan et al.7 Finally, this study presented the information as bullet points with no graphics so clinicians that want to create their own but are hesitant due to making them look more artistic should not worry.
References

  1. Engers A, Jellema P, Wensing M, van der Windt D a. WM, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057. doi:10.1002/14651858.CD004057.pub3
  2. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  3. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  4. Viana da Silva P, Kamper SJ, Robson E, et al. “Myths and facts” education is comparable to “facts only” for recall of back pain information but may improve fear-avoidance beliefs: an embedded randomized trial. J Orthop Sports Phys Ther. Published online July 8, 2022:1-29. doi:10.2519/jospt.2022.10989
  5. Peter C, Koch T. When Debunking Scientific Myths Fails (and When It Does Not): The Backfire Effect in the Context of Journalistic Coverage and Immediate Judgments as Prevention Strategy. Sci Commun. 2016;38(1):3-25. doi:10.1177/1075547015613523
  6. Cornelis E, Cauberghe V, De Pelsmacker P. Two-Sided Messages for Health Risk Prevention: The Role of Argument Type, Refutation, and Issue Ambivalence. Subst Use Misuse. Published online April 22, 2013. doi:10.3109/10826084.2013.787093
  7. O’Sullivan PB, Caneiro JP, O’Sullivan K, et al. Back to basics: 10 facts every person should know about back pain. Br J Sports Med. 2020;54(12):698-699. doi:10.1136/bjsports-2019-101611

 

 

Pathway For Patients With Low Back Pain

Welcome back to SpineIQ’s Back Blog! Most of the blogs that we write summarize studies in primary care or outpatient clinics (e.g., chiropractic or physical therapy offices). These studies provide direct clinically relevant results for conservative spine clinicians. However, we occasionally summarize studies that assess treatments that may be out of the scope of conservative spine clinicians (e.g., medications or spinal injections) as we believe that keeping up with all the evidence in spine pain can help clinicians find the best treatment for the patient in front of them. This week, we will be summarizing the evidence from a cohort study that assessed patients seeking care for low back pain in the emergency department.1 While most conservative spine clinicians do not practice in emergency departments, approximately 4.3 million emergency departments visits are due to low back pain.2 Therefore, we believe it is important for conservative spine clinicians to understand the type of care delivered for low back pain in the emergency department, which may be helpful when seeing patients that have sought care at emergency department previously or when networking with emergency department physicians or nurses.

Aim and methods

While a substantial amount of emergency department visits yearly is due to low back pain, there are no clinical practice guidelines currently that advise emergency department physicians on low back pain. The current clinical practice guidelines for low back pain that we commonly discuss on SpineIQ’s Back Blog (e.g., ACP and NICE)3,4 were created for primary care, which are less likely to see sinister disease, more likely to have multiple visits to follow up, and patients may be less inclined to be seeking imaging/opioids compared to emergency department settings. Therefore, this study is the first step into assessing the current emergency department low back pain care pathway, treatment, and patient outcomes for low back pain. Patients seeking care for low back pain in the emergency department were screened and those with more sinister conditions (e.g., cauda equina syndrome, fracture, infection) were excluded.

Results

There was a total of 337 patients seeking care in the emergency department for low back pain that were screened. Of those 337 patients, 171 were excluded for having a musculoskeletal condition that was not low back pain, 8 were excluded for fractures, 8 were excluded for kidney stones, 7 were excluded for infection, and 40 were excluded for having other non-musculoskeletal diagnosis. The percentage of patients seeking care in the emergency department for low back pain that were excluded for having sinister disease in this study was 5%, which is much higher than the estimated <1% in primary care setting.

Below are the results of the 103 patients that were included in the study:

Type of previous care:

  • 36% of patients had previously sought care at an emergency department for low back pain
  • 59% of patients had previously sought care for low back pain
  • 31% of patients had received an opioid for low back pain within the last 3 months

Type of treatment given in the emergency department:

  • Medications:
    • 41% of patients were given NSAIDs
    • 36% of patients were given opioids
    • 27% of patients were given mental health medication
    • 19% of patients were given acetaminophen
    • 9% of patients were given no medication
    • 9% of patients were given steroid
    • 7% of patients were given muscle relaxants
  • Imaging:
    • 36% of patients received an X-ray
    • 46% of patients received CT/MRI
    • 15% of patients received an ultrasound
    • 33% of patients received no imaging
  • Referral:
    • 21% were referred to Primary Care
    • 14% were referred to physical therapy
    • 12% were referred to orthopedic surgery
    • 9% were referred to neurosurgery
    • 1% were referred to psychiatrist
    • 66% received no referral

Outcomes:

  • There was a clinically relevant improvement of 10.8 points on the PROMIS PFSF-12 at 6-week follow-up
  • There was a clinically relevant improvement of 3.2 points on pain intensity at 6-week follow up

Future care seeking:

  • 24% sought care from primary care provider
  • 15% sought care from emergency department
  • 12% sought care from physical therapist
  • 12% sought care from chiropractor
  • 10% sought care from orthopedic surgery
  • 7% sought care from neurosurgery
  • 3% sought care from urgent care
  • 2% sought care from massage therapist

Conclusions

A substantial amount of people seek care for low back pain from emergency departments. Approximately half of those people have previously sought care from non-emergency departments, which makes it likely that some have been treated by a conservative spine clinician.  Additionally, even though only 14% of the patients were referred to physical therapy and none were referred to chiropractic or massage, approximately 26% of people sought care from a conservative spine clinician (physical therapist, chiropractor, or massage therapist) within 6 weeks of their emergency department visit. Therefore, it is likely that conservative clinicians will see patients that have recently sought care or will seek care for low back pain from an emergency department. These patients are likely to receive imaging and conservative spine clinicians must be prepared to discuss the findings of the imaging and the low correlation of imaging findings with pain. It is critically important for conservative spine clinicians to explore the history and determine what testing was done and obtain the results and or imaging prior to beginning treatment. Finally, there is substantial room for improvement on the referral patterns of emergency department physicians to conservative spine clinicians for patients seeking care for low back pain. In 2022 there is an enormous opportunity for conservative spine clinicians to become one of the clinicians that ER physicians refer to.  Today it is not a question of bias or prejudice but rather simply a question of awareness. Research has almost removed the bias, but it is difficult to change habit patterns and in institutions such as hospitals protocols and past referral patterns. This presents an opportunity for conservative spine clinicians to network with their local emergency department physicians, introduce themselves and their guideline concordant treatment, which may increase future referrals when appropriate. There has never been a more appropriate time for conservative care protocols to be discussed and implemented.

References

  1. Magel J, Suslavich K, Roper K, Fritz J, Madsen T. Emergency department evaluation, treatment, and functional outcomes among patients presenting with low back pain. Am J Emerg Med. 2022;59:37-41. doi:10.1016/j.ajem.2022.06.048
  2. Edwards J, Hayden J, Asbridge M, Gregoire B, Magee K. Prevalence of low back pain in emergency settings: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2017;18(1):143. doi:10.1186/s12891-017-1511-7
  3. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
  4. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/

Empowering Patients To Use Self-Management Strategies

Welcome back to SpineIQ’s BackBlog! For the past couple of weeks, we have been discussing one of the main topics that is consistent throughout clinical practice guidelines for low back pain: imaging. This week, we discuss another one of the topics that is consistent throughout clinical practice guidelines for low back pain: self-management.1 A group of researchers that are leading pragmatic clinical trials for chronic pain, including Dr. Goertz, recently wrote an article with a call to action to improve the implementation of self-management strategies for chronic pain. In this blog, we summarize their call to action and provide clinically relevant suggestions to empower patients to use self-management strategies.

What is self-management?

Self-management has been defined as intentionally attempting to manage your own pain experience.2 The potential for self-management is associated with self-efficacy, which is the belief that one can achieve successful pain management. In a previous blog, we discussed that patients tend to feel positive towards self-management, but self-doubt can decrease this positive feeling towards self-management. This is where the provider plays an extremely important role in being able to reassure, foster increased resilience, and empower the patients to work through these periods of self-doubt.3

What are the clinically relevant competencies for self-management?

In the article by Kerns et al. titled “self-management of chronic pain: psychologically guided core competencies for providers”, the authors discuss clinically relevant competencies for self-management. These include the 4 overarching competencies of recognizing the multidimensional nature of pain, pain assessment, pain management, and the clinical and social context. Each overarching competency provides clinicians with suggestions on how to empower patients and promote self-management strategies. Some of the clinically relevant suggestions are:

  • Use active listening and motivational interviewing skills to educate on the multidimensional, biopsychosocial nature of pain while acknowledging the patients unique pain experience
  • Reassure patient by letting them know that they are in charge, can manage their pain and the effect it has on their life
  • Through a shared decision making process, identify barriers and facilitators to self-management and build a plan to empower self-management
  • Promote healthy behaviors (e.g., exercise and nutrition), while actively listening and discussing potential barriers to increasing healthy behavior and building a plan through shared decision making to limit the effect of those barriers
  • When appropriate, ask to engage friends/family that can help empower patients to get back to doing the things they love to do

Conclusions

The evidence is strong for the importance of self-management for chronic pain. This has led to consistent clinical practice guideline recommendations encouraging clinicians to promote self-management. However, the authors of this article acknowledge the need of a call to action in the implementation of self-management strategies in routine clinical practice. The authors list two key factors that have influenced the slow up-take of self-management for chronic pain: training and reimbursement. We hope that the clinically relevant suggestions in this blog, along with previous blogs on (1) guidance for self-management, (2) how to build successful self-management plans, and (3) barriers and facilitators to supporting self-management, can help increase the knowledge and training of self-management among clinicians. We recognize that this is a very difficult challenge for clinicians, however even one successful patient who has been successful in self-management will provide the momentum and encouragement to both the patient and the clinician. The reward of self-management which is gratifying for the patient and clinician, will yield confidence from staff and other patients who will soon recognize that this practice and practitioner are different.

References:

  1. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  2. Medicine I of. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; 2011. doi:10.17226/13172
  3. Bourke MJ, Ferguson D, Cooke M. Patient Experiences of Self-Management for Chronic Low Back Pain: A Qualitative Study. Phys Ther. Published online March 30, 2022:pzac030. doi:10.1093/ptj/pzac030

 

 

Low Back Pain Imaging: Are Patients & Clinicians on the Same Page?

Welcome back to SpineIQ’s Back Blog! Last week, we summarized the overarching literature surrounding clinicians’ beliefs of barriers and facilitators for guideline concordant imaging of low back pain. Many of the results surrounded clinician beliefs about patient expectation for low back pain.1,2 A systematic review by Sharma et al. was conducted to assess whether these beliefs by clinicians are concordant with patients’ beliefs about imaging for low back pain.3 This study titled, “Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis” found 69 studies that explored patient or general public beliefs about diagnostic imaging for low back pain and compared the beliefs to clinician beliefs about patients. In this blog, we summarize the findings and discuss the clinically relevant results.

Findings

After screening 6109 studies, 69 studies were included and analyzed in this systematic review. Several themes were found throughout the studies with moderate to high confidence. These themes found beliefs that were concordant and discordant between patient and clinician.

Concordant beliefs between patient and clinician:

  • Imaging is helpful to find and locate the pathoanatomical source of low back pain (high confidence)
  • Findings on imaging legitimized (patient belief) and reassured (clinician belief) the low back pain experience

Discordant beliefs between patient and clinician

  • Some clinicians were aware that imaging is not helpful for diagnosing non-specific low back pain, but patients were not aware of this
  • Some clinicians believed that patients would be reassured by a negative test, however, negative tests distressed patients since it “showed nothing”
  • Patients felt scared if the findings of the imaging were described as permanent, degenerative, or irreversible and some clinicians were unaware of this possibility

Conclusions

These findings add context to our blog summarizing clinicians’ beliefs about barriers and facilitators to guideline concordant low back pain imaging. There are 5 patient beliefs that were high or moderate confidence with 2 of them concordant and 3 discordant with clinicians’ beliefs. While some clinicians were aware that imaging is not a helpful diagnostic tool and can lead to negative consequences (e.g., radiation or waste of resources), not all clinicians were aware of this, and no patients were aware. In order to inform patients, informational one-page handouts, posters in waiting area, and evidence-based information on the website or through patient facing weekly blogs may increase patient awareness of the evidence surrounding low back pain imaging.4 For clinicians that are not aware of the most up-to-date evidence surrounding low back pain imaging, it is possible that dissemination of evidence for the busy clinician may be useful.5 Clinics with numerous clinicians can dedicate a weekly time to discuss evidence or give presentations in order to stay up-to-date with the current evidence. Finally, clinicians were not aware that both “inconclusive” and “degenerative” findings could lead to stress for patients. This is a negative consequence that clinicians should be aware when deciding whether to order imaging for low back pain and should communicate the possibilities of these findings with their patient prior to ordering the imaging. Through conversation about the low correlation between imaging findings (whether inconclusive or degenerative) and prognosis for low back pain, the patient may be less stressed and uncertain when imaging results return or best-case scenario, patient chooses to not want imaging since the findings are unlikely to provide useful information on management or prognosis.

References

  1. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of Magnetic Resonance Imaging. JAMA Intern Med. 2013;173(9):823-825. doi:10.1001/jamainternmed.2013.3804
  2. Downie A, Hancock M, Jenkins H, et al. How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. Br J Sports Med. 2020;54(11):642-651. doi:10.1136/bjsports-2018-100087
  3. Sharma S, Traeger AC, Reed B, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820. doi:10.1136/bmjopen-2020-037820
  4. Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a Waiting Room Communication Strategy on Imaging Rates and Awareness of Public Health Messages for Low Back Pain. Int J Qual Health Care. 2021;(mzab129). doi:10.1093/intqhc/mzab129
  5. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008

 

 

Tips To Overcome Barriers Surrounding Unnecessary Imaging

Welcome back to SpineIQ’s BackBlog! As most of you know, we are strong advocates for appropriate care for spinal pain as outlined in numerous evidence-based guidelines. Such guidelines have been created by a variety of organizations with the goal of assisting clinicians in in adhering to best practices for care.1 The majority of clinical practice guidelines have recommended conservative care, such as manual therapy and exercise, as first-line treatment for spinal pain.2 Another consistent recommendation is to avoid imaging (x-ray or MRI) for the majority of patients who are likely experiencing non-specific low back pain, defined as low back pain with no specific cause.3,4 Studies have shown that nearly half of the imaging currently ordered for low back pain is unnecessary, leading the Choosing Wisely campaign chose it as one of its aims to reduce low value care.4,5 In this week’s BackBlog, we summarize the research on barriers and facilitators to following clinical practice guideline recommendations on imaging. Our goal is to ensure that this critically important but overused diagnostic tool is only utilized in those instances when it is appropriate, such as suspicion of underlying disease.

Barriers and Facilitators

Several studies have qualitatively assessed clinicians’ thoughts on barriers and facilitators to appropriate low back pain imaging. These studies have been conducted in different health care settings (e.g., primary care and emergency department) and different countries. However, the same themes of barriers and facilitators are reported, including the following:

  • Patients want imaging and pressure clinicians into providing it (barrier)
    • Alternative – patients may be reassured by education on why imaging is not necessary in their particular situation
  • Reassuring the patient (barrier)
    • Alternative – patients may be reassured by the confident evidence-based approach to diagnosis and treatment taken by the clinician
  • Lack of time to inform patients that imaging is not needed (barrier)
    • Alternative – indicating that imaging is not needed initially but may be considered later may reassure the patient that the clinician is aware of other diagnostic options.
  • Fear of missing a serious illness (barrier)
    • Alternative – it is important that the benefits vs risks be considered for each individual patient. The benefit of catching a rare underlying condition must be weighed against the risk to the patient of unnecessary imaging (cost and the potential for worse outcomes)5
  • Using one-page patient handouts to help inform the patient in a timely manner (facilitator) Patient information sheets that are discussed with the patient and noted in the chart demonstrates that imaging was not overlooked but rather not deemed appropriate at this particular time.
  • Staying up-to-date with the evidence increases confidence in not ordering imaging (facilitator).

Conclusion

There are numerous self-reported barriers and facilitators that influence a clinician’s imaging behaviors related to low back pain. While some patients are likely to want imaging regardless, there are things that clinicians can do to lower this expectation. For example, purposefully using the poster and wall area in the clinic to hang informational posters focused on evidence-based information about when imaging is unnecessary and the cascade of unnecessary care that can happen when inappropriate imaging is ordered can help inform patients while they’re waiting.6 Clinicians can also have one-page handouts ready for patients to inform them in a timely manner. While clinicians report that they believe patients will be reassured by imaging, studies show that this is often not the case. Instead, patients are often confused when imaging does not identify a specific cause for their pain.7 While ordering imaging may be faster in the short run, the time saved from ordering the imaging may be lost due to future conversations explaining why imaging findings don’t strongly correlate with symptoms or prognosis. Finally, some clinicians use imaging as a “fail-safe” to protect themselves from missing something. It is important, not only for the patient, but for the clinician to remember that less than 1% of low back pain is due to a threatening disease.8

Reference

  1. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management. National Institute for Health and Care Excellence (UK); 2016. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK401577/
  2. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  3. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189. doi:10.7326/0003-4819-154-3-201102010-00008
  4. Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012-14. Health Aff Proj Hope. 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263
  5. Delitto A, Patterson CG, Stevans JM, et al. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. eClinicalMedicine. 2021;34. doi:10.1016/j.eclinm.2021.100795
  6. Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a Waiting Room Communication Strategy on Imaging Rates and Awareness of Public Health Messages for Low Back Pain. Int J Qual Health Care. 2021;(mzab129). doi:10.1093/intqhc/mzab129
  7. Sharma S, Traeger AC, Reed B, et al. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820. doi:10.1136/bmjopen-2020-037820
  8. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X

 

 

 

Long-Term Effectiveness of Epidural Steroid Injections

Welcome back to SpineIQ’s Back Blog! While we usually write blogs geared towards treatments within the scope of conservative spine clinicians, it is important that conservative spine clinicians keep up regarding the evidence base of treatments commonly administered by other clinicians for spine pain. Patients will ask your opinion about treatments they are considering and you need to be able to make informed referrals. Therefore, this week we are summarizing the clinically relevant findings of Curatolo et al. titled “Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults.”1

Aims and Methods

In 2018, there were 2.2 million epidural steroid injections performed on older adults (65+ years).2 Epidural steroid injections are commonly performed for low back pain that involves radicular pain. The goal of this study was to determine whether 1) patients that receive epidural steroid injections are in worse pain at baseline compared to patients that do not receive epidural steroid injections and 2) if epidural steroid injections have an effect on pain, function, or quality of life in older adults with radicular pain and low back pain.

Patients age 65 and older that had not sought care for low back pain within the last 6 months were included in the study. Participants were separated into three groups. Group 1 included  patients who received epidural steroid injection within 6 months of recruitment. Group 2 included patients who did not receive epidural steroid injection, lumbar surgery, other injection, or radiofrequency ablation within 6 months. Group 3 included patients who did not receive epidural steroid injection or other low back procedure but were matched with patients in Group 1 based on their baseline pain characteristics. Pain intensity, function, and quality of life were collected at baseline and then again at 3, 6, 12, and 24 months.

Results

295 patients were included in Group 1, 4809 patients were included in Group 2 and 483 patients were included in Group 3. 74% of patients in Group 1 received an epidural steroid injection within 3 months, with the rest receiving it between 3 and 6 months.

Study authors found that patients who received epidural steroid injections had worse symptoms (pain intensity 5.8 on a 0-10 scale) compared to those that did not receive epidural steroid injections (pain intensity 2.9 on a 0-10 scale). Further, when they compared Group 1 participants to Group 3 participants, they found that both groups experienced significant improvement over time but there was no difference between the groups.

Conclusions

These findings are relevant for clinicians that treat people with low back pain for several reasons. First, it is essential to provide evidence-based answers to questions posed by patients about alternative treatment options, including patients with higher levels of pain. Second, understanding that epidural steroid injections may not be significantly more effective than the passing of time for older adults with low back pain and radicular pain may influence your decision-making process when making referrals, especially when also considering the risk of serious spinal adverse events (5.1 per one million) associated with this procedure .3 Legal note: clinicians should proceed with caution when discussing treatments that are out of their scope even with evidence to support their suggestions. It is important to inform patients of the risks and benefits regarding a range of treatment options and, as always, appropriately document these conversations in the patient record.

References

  1. Curatolo M, Rundell SD, Gold LS, et al. Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults. Eur J Pain Lond Engl. Published online May 23, 2022. doi:10.1002/ejp.1975
  2. Manchikanti L, Sanapati MR, Soin A, et al. An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018. Pain Physician. 2020;23(2):111-126.
  3. Eworuke E, Crisafi L, Liao J, et al. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med. 2021;46(3):203-209. doi:10.1136/rapm-2020-101778