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Applying Shared Decision Making to Low Back Pain

Applying Shared Decision Making to Low Back Pain

ABSTRACT: Shared decision making for guiding medical/surgical management of patients with low back pain (LBP) involves concerns about regional variation in health care, patient autonomy versus
physician paternalism, and the degree of patient involvement. The evidence base about chronic LBP is addressed in several questions (eg, how common is LBP? what treatment is appropriate?). The "logical plan" for patient care includes sparing use of medications, providing pain relief, and quick resumption of work. Regional variance may be overcome by recognizing that not all patients are best served by fusion, that individual patient and physician factors/preferences need to be weighed carefully, and that providing unbiased presentation of the best available evidence on the patient's therapeutic options facilitates such careful weighing. (
J Musculoskel Med. 2008;25:421-427)

Shared decision making as a preferred method to guide the medical/surgical management of patients is a somewhat new concept. At its foundation rests the contemporaneous emergence of the following 3 independent principles of modern health care: (1) that regional variation in health care is bad; (2) that patient autonomy trumps physician paternalism; and (3) that patients are consumers who should be actively involved in deciding what they purchase.

Although each principle may be and has been debated, together they have been accepted as guiding ideals over the past 30 years. Each principle has a unique and interesting history, but their histories before the 1970s are but trickling streams compared with the river formed with their confluence. In this article, we discuss the application of shared decision making principles to spine care, particularly management of patients with low back pain (LBP).

Regional variation and spine care
Concerns about regional variation in health care may be traced to surgical rates of tonsillectomy in the United States in the 1920s, when American Child Health Association researchers monitored 1000 11-year-old New York City public school students. At the start of the study, 61% of the students already had had tonsillectomies. The others were sent to a group of school doctors, and 45% of them were told that they needed a tonsillectomy. The remaining students were redistributed to the school doctors, and 46% of them were referred for tonsillectomy, and so on. In the end, only 65 of the original 1000 children were not recommended for tonsillectomy—if the children eventually saw the "right" doctor, they would be recommended for surgery.

A decade later in England, Glover reported his classic findings that tonsillectomy rates vary widely based on geographic region. Half a century later, Wennberg published his classic findings that such variation is true not only for tonsillectomy but also for multiple interventions and pathologies (including spine care, where operative rates were found to vary dramatically among well-defined small geographic regions) and that such variation appears to have more to do with the number of physicians in the region, their medical/surgical specialties, and the procedures they prefer to perform than with the health of presenting patients.

This "conclusion" was not popular among doctors, and it was alternatively suggested that the variation problem might not lie with the physicians/surgeons but rather with the lack of high-quality evidence about what is the best available treatment for any particular pathology. Hence, the "outcomes movement" and "evidence-based medicine" arose to provide quality evidence for medical/surgical decision making.

The evidence base and spine care
Although spine care practitioners as a group often are characterized as aggressive, they have emerged as leaders in the development of a solid evidence base. Since the mid-1970s, randomized controlled trials (RCTs) studying the efficacy of interventions aimed at LBP have numbered in the thousands. Also, the "per-year" production and quality of such studies continue to rise as a result, not in small measure, of the emphasis placed here by the leading spine societies and in the journal Spine under the guidance of James Weinstein at Dartmouth.

Based on these studies, the evidence base about chronic LBP (not including sciatica, disk herniation, spinal stenosis, and gross deformity) is addressed in the following questions:

How common is LBP? The point prevalence is about 33%, and the 1-year prevalence may be as high as 73%.


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