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The Somatic Connection  |   July 2018
Treating Patients With Low Back Pain: Evidence vs Practice
Author Notes
  • Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest, Lebanon, Oregon 
  • Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California 
Article Information
The Somatic Connection   |   July 2018
Treating Patients With Low Back Pain: Evidence vs Practice
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 486-487. doi:https://doi.org/10.7556/jaoa.2018.107
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 486-487. doi:https://doi.org/10.7556/jaoa.2018.107
Foster NE, Anema JR, Cherkin D, et al; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions [published online March 20, 2018]. Lancet. doi:10.1016/S0140-6736(18)30489-6 
Low back pain (LBP) is the third-most common cause of visits to ambulatory clinics in the United States.1 With a lifetime prevalence reaching 84% and numerous contributory factors adding to diagnostic and treatment complexity,2 expert panels, medical specialty societies, professional associations, and government regulatory bodies around the world have established guidelines in attempts to optimize resources and treatment outcomes. However, it is unclear whether these “best practices” guidelines are upheld or followed by practicing clinicians. 
Because of this growing problem, researchers from the United Kingdom, the United States, and the Netherlands investigated global LBP management guidelines, including provider compliance and efforts to improve compliance. They used PubMed and Scopus to search for relevant research and directly contacted experts and researchers in countries where data were limited. A majority of the guidelines recommend improving function through exercise and nonpharmacologic therapies, including acupuncture, spinal manipulation, Tai Chi, and yoga. Strong focus was also placed on addressing patients’ biopsychosocial needs. 
What was seen in clinical practice was far from current recommendations. In the United States, exercise was prescribed for about 50% of patients with chronic LBP, opioids were prescribed for 61%, and long-term opioid therapy was prescribed for 18%. Spinal fusion, facet injections, and neurotomies were used frequently even though evidence supporting these modalities is limited. Also in the United States, only 12% of patients with LBP and comorbid depression had seen a mental health professional within the past year. These current practices drain health care resources and can adversely affect patients, including exposure to unnecessary radiation and interventions. 
Some cited factors contributing to physician noncompliance include poor guideline education, short consultation times, fear of litigation, and the desire to maintain strong relationships with patients. Efforts to increase physician compliance have had varying degrees of success, with the strongest evidence supporting programs with continuous reminders of guidelines. 
This study was limited by the amount of data from low- and middle-income countries, an unclear article selection process, and vague research methods without additional data analysis. There was no mention of the American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain,3 which strongly recommends OMT for patients with acute or chronic LBP. However, despite these limitations, this study clearly sheds light on the substandard care of LBP, raises concerns about what percentage of DOs comply with the American Osteopathic Association's guidelines, and brings into question how many patients have access to recommended care. 
References
Sauver JL St, Warner DO, Yawn BP, et al. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clin Proc. 2013;88(1):56-67. doi: 10.1016/j.mayocp.2012.08.020 [CrossRef] [PubMed]
Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258. doi: 10.1001/archinternmed.2008.543 [CrossRef] [PubMed]
Task Force on the Low Back Pain Clinical Practice Guidelines. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain. J Am Osteopath Assoc. 2016;116(8):536-549. doi: 10.7556/jaoa.2016.107 [CrossRef] [PubMed]