Treatment Options for Back Pain

Opportunity Snapshot

As part of PCORI’s effort to investigate and fund useful, impactful research on critical patient-centered health and healthcare issues, we are turning to you, the public, to provide us with information on which questions are of personal importance regarding treatment options for back pain. We would like your input on which questions in this topic are unanswered, which treatments should be compared, and which are the most important patient-centered outcomes that need to be addressed. Our objective is to identify those questions that are most important from the patient’s perspective—those questions, that if answered, would contribute the most to helping patients affected by back pain to make better-informed healthcare choices and improve healthcare outcomes.

Overview
Patients with back pain without neurological deficit or spinal deformity are at risk for recurrences, long-term chronic pain, limitations in ability to function, and reduced quality of life. Back pain treatment options are numerous and varied, and include physical therapy, strength training, medication therapy, chiropractic, massage, acupuncture, and surgical options. There is, however, a lack of clarity regarding which treatment strategies are more effective than others and particularly how treatment effectiveness may differ among patients. Due to the unspecified nature of much back pain, the broad spectrum of treatment options and inconsistent research patients face much uncertainty about how to choose the best treatments for multiple types of back ailments that result in pain.

Background
Back pain is a common patient complaint and ranks behind only cold symptoms as the most frequent reason for a visit to a physician.¹ Back pain is attributed to many diagnoses, which can be grouped broadly as: injuries, disc disorders, and spine disorders. Standard medical care for most diagnoses includes nonsurgical and surgical treatments, including rest, medications (such as pain killers or muscle relaxants), physical therapy, transcutaneous electrical nerve stimulation (TENS), rhizotomy (surgically severing a nerve), spinal manipulation, acupuncture, cognitive behavior therapy, biofeedback, exercise, and aquatic therapy.^2,3

To make matters more complicated, care is often sought from a range of providers, including primary care physicians, chiropractors, rheumatologists, orthopedic surgeons, and neurosurgeons.⁴ Risk factors for back pain include aging, genetics, occupational hazards, lifestyle, weight, posture, and smoking.³ People older than 30 to 40 years are at risk for wear and tear on the spine, resulting in conditions such as disc degeneration and spinal stenosis. Patients older than 60 years are more likely to have back pain related to osteoarthritis. There is also some evidence that genetics plays a role in certain types of spinal disorders, such as degenerative disc disease.⁵

Although the majority of cases of uncomplicated back pain resolve within a 12-week period, there is a high recurrence rate, which leads to significant financial cost and personal disability; a small percentage of patients experience prolonged disability.¹ The impact that this condition has on the US healthcare system is substantial. The United States Bone and Joint Decade estimates that 5 percent of patient visits to physician offices and hospitals in 2006 were due to back pain.⁶ Analysis of 2004 data estimate the annual cost of medical care for spine conditions to be $193.9 billion, $30.3 billion of which is directly attributed to healthcare costs (e.g., healthcare provider visits, hospitalizations, medications, etc.).⁶

Despite this impact, there remains a lack of evidence regarding which treatment options are best. PCORI views this gap in the evidence base as an area where we can contribute to improving health and healthcare outcomes. We believe there is need for large-scale comparative effectiveness studies that examine the most effective and safest courses of treatment that will result in the alleviation of back pain, regardless of cause, with a focus on patient preferences and needs.

Research Areas of Interest
We have identified the following specific topic areas for back pain treatment as areas of potential research funding:

• Questions that compare multidisciplinary treatment approaches with single treatment approaches for pain reduction and other patient-reported outcomes in people with chronic back pain. Questions that address the effectiveness of various treatments or combinations of treatments for reducing chronic pain.
• Questions that identify the most effective treatment strategies for different patient subpopulations.
• Questions that identify the most effective treatment strategies for the various causes of back pain.
• Questions that compare treatments in order to evaluate the relative effectiveness of the available treatments for pain reduction and other patient-reported outcomes.

We ask you to submit your questions about the treatment of back pain and help us define which critical questions in this topic area should be further explored.

About Our Workgroup Process

For each topic considered as part our accelerated process to develop targeted PCORI funding announcements, we will convene an ad hoc workgroup to provide input on research gaps in the current evidence base and critical near-term research questions that, if answered, will improve health. Consistent with our core value of inclusiveness, each workgroup is comprised of a diverse group of researchers, patients and other stakeholders. Each workgroup will meet once in the second quarter of 2013. Meetings will be accessible through audio-conference, webcast, or other forms of communication, and, through our website, any interested individual can contribute comments, suggestions, and input for up to two weeks before, during, and for two weeks after each meeting. Learn more about the workgroup selection process for treatment options for back pain.

Submit a Question or Comment

The question and comment period for this topic has now closed. PCORI staff will review all questions and comments received on this topic, as well as the deliberations of the ad hoc workgroup that met March 21, and recommend questions for our Board of Governors to consider approving as the basis of topic-specific PCORI Funding Announcements. We hope to release such announcements by mid-year.

We were very pleased to see how many people contributed to this process by viewing the webinar of our ad hoc workgroup’s proceedings or submitting questions or comments through our website or via email. In coming months, we will post a summary of the workgroup’s meeting as well as a full record of all of the questions we received. Stay up to date on this process, and all of PCORI’s activities, by signing up for our email alerts.
 

1. Andersson GBJ. Epidemiological features of chronic low-back pain. Lancet. 1999;354:581-585.
2. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):492-504.
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). What is back pain? Fast facts: An easy-to-read series of publications for the public. 2009. Available at: http://www.niams.nih.gov/Health_Info/Back_Pain/back_pain_ff.asp. Accessed January 28, 2012.
4. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. New Engl J Med. 1995;333(14):913-917.
5. Patel AA, Spiker WR, Daubs M, Brodke D, Cannon-Albright LA. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am. 2011;93(3):225-229.
6. United States Bone and Joint Initiative. Spine: Low back and neck pain. In: The Burden of Musculoskeletal Diseases in the United States, Second Edition. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:21-56.

Posted Feb. 8, 2013