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
- 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
- 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
- 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
- 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/