Welcome back to the SpineIQ BackBlog! This week, we will be discussing one of the most often discussed topics surrounding low back pain. A recent publication by O’Keeffe et al. sought to study the potential effects of diagnostic labelling of low back pain using a novel online randomized controlled trial approach.1 Currently, most guidelines state that majority of low back pain (85-95%) is not likely to be sinister or come from a specific structure like fractures, infections, or malignancy.2–4 In fact, research on imaging of people without low back pain revealed that degeneration, arthritis, and disc bugles are common in asymptomatic people leading to guideline recommendations to avoid unnecessary imaging.5,6 However, communicating that positive prognosis of most low back pain without making the patient feel like their low back pain is not important can be troubling for clinicians. This has led to a debate on what is the best way to communicate a diagnosis of low back pain to patients. Therefore, O’Keeffe et al. assessed whether diagnosis label for low back pain influences the likelihood to perceive need for imaging, surgery, secondary opinion, seriousness of low back pain, recovery expectations, and ability to engage in work.
Aims and Methods
Using an online survey website (Qualtrics.com) this study randomized people with low back pain that sought care, people with low back pain that have not sought care, and people that have never experienced low back pain to a specific scenario.
Scenario: Participants were all told that they were seeking care for low back pain from a primary care clinician. They were then randomized to receiving one of the 6 diagnosis for their low back pain of “disc bulge”, “degeneration”, “arthritis”, “lumbar sprain”, “non-specific low back pain”, or “episode of low back pain.” After receiving the diagnosis, all participants were reassured with “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better.”
After the scenario, participants were asked on a Likert scale from definitely not to definitely do, whether they perceived need for imaging, surgery, second opinion, seriousness of low back pain, recovery expectations, and ability to work.
Results
Overall, 1,375 participants were randomized to one of the 6 diagnostic labels for low back pain. Importantly but to little surprise, the hardest group to recruit was people that had never experienced low back pain. This is likely due to most people experiencing low back pain at some point. Below are the results for each outcome from best to worst diagnosis.
- For imaging, “episode of low back pain” (best), “lumbar sprain” and “non-specific low back pain” led to significantly less perceived need for imaging compared to “disc bulge”, “degeneration”, and “arthritis” (worst).
- For surgery, “non-specific low back pain” (best), “lumbar sprain”, and “episode of low back pain” led to significantly less perceived need for surgery compared to “disc bulge”, “arthritis”, and “degeneration” (worst).
- For second opinion, “lumbar sprain” (best), “episode of low back pain”, and “non-specific low back pain” led to significantly less perceived need for secondary opinion compared to “disc bulge”, “degeneration”, and “arthritis” (worst).
- For seriousness of low back pain. “non-specific low back pain” (best), “lumbar sprain”, and “episode of low back pain” led to less perceived seriousness of low back pain compared to “disc bulge”, “arthritis”, and “degeneration” (worst).
- For recovery expectations, “lumbar sprain” (best), “episode of low back pain”, and “non-specific low back pain” led to higher recovery expectations compared to “degeneration, “disc bulge”, and “arthritis” (worst).
- For engaging in work, “non-specific low back pain” (best), “lumbar sprain”, “episode of low back pain”, “arthritis”, and “disc bugle” are more likely to engage in work compared to “degeneration” (worst).
Conclusion
This study provides clinically relevant results of what diagnostic labels may be more likely to increase detrimental perceptions of unnecessary care (e.g., imaging or surgery). The words that clinicians use has been shown to have a large impact on patients in previous studies, therefore, these results should not be too surprising.7 It appears that using diagnostic labels of “lumbar sprain”, “non-specific low back pain”, or “episode of low back pain” can have a positive impact on numerous low back pain-related outcomes (e.g. imaging, surgery, second opinion etc.) compared to “disc bulge”, “degeneration”, or “arthritis.” Simple language change by clinicians can be clinically meaningful for low back pain patients.
References:
- O’Keeffe M, Ferreira GE, Harris IA, et al. Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment. Eur J Pain. n/a(n/a). doi:10.1002/ejp.1981
- Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet Lond Engl. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9
- 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/
- 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
- 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
- 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
- Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Ann Fam Med. 2013;11(6):527-534. doi:10.1370/afm.1518