Validity
The results suggest a positive effect of the intervention, but the complex nature of the study design raises some concerns. To conclude that the educational program in the RCT led to improved patient outcomes, one has to assume that patients (1) treated in both the RCT and observational studies were similar in terms of the risk factors affecting back pain duration and recovery, and (2) and that nothing besides the educational intervention changed the way the physicians treated back pain patients in the 2 different studies. In fact, there were some significant differences between the patients in the 2 studies, such as income, workers’ compensation and employment status, and baseline functioning. The authors controlled for these factors in determining functional outcomes; however, the extent of the differences between the 2 patient groups casts some doubt as to whether they were similar enough to be compared. I would conclude that there is a positive benefit of the education program on patient satisfaction with physician performance and a smaller benefit on patient outcomes. Given the number of studies showing low patient satisfaction with physician care, this result is encouraging and should be explored in other settings.
Population-Based Care
As an alternative to focusing on the treatment end of back pain, it might be useful for primary care physicians to step back from the patient (the numerator) and consider the larger population with back pain (the denominator). For instance, the Agency for Health Care Policy and Research clinical guideline indicates the yearly prevalence of back pain as 50% in working-age adults of whom only approximately one sixth seek care.1 Are there some specific characteristics of these people that lead them to our offices?
Efforts to identify the risk factors of those who seek medical care for acute back pain and who develop chronic back pain have not produced clear results. The strongest predictor is a history of back pain. Effects of psychosocial factors, the work environment, and workers’ compensation may have a role. Hadler14-16 has written extensively on the lack of research to support the role of physical stress, particularly that which is work related, as an explanation. He argues persuasively that the workers’ compensation system has changed the concept of back pain from that of an illness or predicament into an injury. This transformation has often been aided by the efforts of physicians, pharmaceutical companies, and alternative medicine providers, who proffer ways to fix the pain. Hadler proposes that we identify the different ways people have for coping with this common ailment while it takes its natural course.
The argument about the role of the workers’ compensation system in the care of back pain suggests that a public health approach—one that takes into account policy development, as well as treatment—may be a useful strategy. Recent research on whiplash injuries that demonstrates a decrease in insurance claims for pain and suffering after changes in the tort system may offer different strategies to better support recovery from back pain.17 This is not to suggest that patient malingering is the problem; it is not. It does suggest that some back pain may result from a complex interaction of biologic, psychosocial, and economic factors and incentives, and that addressing these issues in both the policy and medical arenas may be of more help to patients.18
Hadler14 offers some simple advice for caring for patients with back pain who lack significant neurologic findings; his suggestions are echoed and elaborated on by Gillette.19 His approach emphasizes identifying the array of factors that may impede recovery (various forms of stress, depression or somatization, and counterproductive beliefs about back disorders), developing a constructive physician-patient relationship, addressing stresses, keeping patients active, and prescribing medication when appropriate. This is good advice for physicians dealing with this common and sometimes frustrating problem.