Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment

Key Points

1. Almost 75% of primary contact clinicians think it is possible to identify the source in all cases of low back pain (LBP) and believe that pathoanatomic labeling is a more appropriate guide for diagnosis and guiding treatment choice.
2. However, the data provided by this study indicates that clinicians should consider not using the labels disc bulge, degeneration and arthritis as part of explanations and reassurance provided to people with non-specific LBP.
3. Changing how we label LBP may help reduce unnecessary medical tests and treatments and increase the acceptability of watchful waiting, self-care and the less intensive treatment options that are recommended in guidelines for the management of non-specific LBP.

BACKGROUND & OBJECTIVE

Low back pain (LBP) is the leading cause of years lived with disability worldwide, and it is the second most common symptom-related reason for seeking care from a primary care provider (1,2). In 2016, in the United States, an estimated $134.5 billion was spent on health services for patients with low back and neck pain, and this spending appears to be consistently and rapidly increasing each year.

The vast majority of LBP (roughly 90-95%) is referred to as “non-specific LBP”. Per LBP clinical practice guidelines, the term non-specific LBP refers to LBP where it is currently not possible to identify a specific structural cause (e.g. radiculopathy, fracture, malignancy) (3).

However, the use of the term “non-specific LBP” has given rise to much criticism. Opponents of the non-specific label claim it is cumbersome to use with patients, conveys that the clinician does not know what is wrong with the patient, provides no pathoanatomical basis for LBP, and is a barrier to the provision of individualized care.

The authors of this study aimed to propose why the use of highly specific and anatomical-based specific structural labels may also be considered problematic.

In 2016, in the United States, an estimated $134.5 billion was spent on health services for patients with low back and neck pain.

Removing labels like degeneration from LBP presentations may play a very low risk, high reward role in helping to shift patients’ perspectives.

METHODS

This study was a six-arm, parallel group, superiority randomized experiment with blinded participants conducted online.

Population

Participants were recruited through Qualtrics and separated into three groups:

1. Adults who currently had LBP and had received formal treatment for LBP at any time in their life (e.g. treatment from a doctor, physical therapist, chiropractor, surgeon, or any other healthcare provider).

2. Adults who currently had LBP and had never received formal treatment for LBP.

3. Adults who had never experienced LBP in their lifetime.

Procedure

All participants were provided the same scenario of attending a primary care clinician about LBP. The scenario described the location of the pain, possible triggering event, and functional limitations. Participants were then randomized to receive one of six diagnostic labels with explanations: “you have a disc bulge”; “you have degeneration of the spine”; “you have arthritis of the spine”; you have a lumbar sprain”; “you have non-specific LBP”; or “you have an episode of back pain”.

All six groups then received the same reassurance from the primary care clinician: “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better”.

Outcomes

The primary outcome was belief about the need for imaging for LBP. This was assessed using a single item on an 11-point Likert scale (0= definitely not; 10= definitely do) with the question: “Do you think you need a scan (for example, an X-ray or MRI scan) of your back?”.

RESULTS

1,375 participants were included in the final analysis. Participants who received the labels “episode of back pain” (mean [SD] 4.2 [2.9]), “lumbar sprain” (4.2 [2.9]), and “non-specific LBP” (4.4 [3.0]) perceived significantly less need for lumbar imaging compared to those receiving the labels “arthritis” (6.0 [2.9]), “degeneration” (5.7 [3.2]), and “disc bulge” (5.7 [3.1]). An “episode of back pain” consistently had the lowest perceived need for imaging in comparison to “arthritis”, “degeneration”, and “disc bulge”, followed by “lumbar sprain” and “non-specific LBP”.

These differences between labels were evident across all three groups of participants. However, there were larger differences for perceived need for imaging between labels for participants with current LBP who had a history of seeking care.

Further, in a secondary analysis assessing participants’ willingness to undergo surgery as measured by a second modified Likert scale, those who received the labels “non-specific LBP” (3.4 [2.8]), “lumbar sprain” (3.6 [2.9]) and “episode of back pain” (3.7 [2.9]) were less willing to undergo surgery compared to those receiving the labels “degeneration” (4.6 [3.0]), “disc bulge” (4.3 [2.9]), and “arthritis” (4.2 [2.9]).

LIMITATIONS

• This study was based on a researcher presented scenario and results may differ in real world situations.

• Outcome measurement was only taken at a single time point immediately after the labels were given. Management preferences may subsequently change as participants reflect over time.

CLINICAL IMPLICATIONS

The results of this study provide evidence that assignment of some diagnostic labels (episode of back pain, lumbar sprain, non-specific LBP) reduced perceived need for imaging, surgery and second opinion compared to other labels (arthritis, degeneration, and disc bulge) among individuals with and without LBP.

Assignment of the same labels (lumbar sprain, non-specific LBP, and episode of back pain) also reduced the perceived seriousness of LBP and increased recovery expectations. Importantly, the impact of labels appears most relevant among those at risk of poor outcome (participants with current LBP who had a history of seeking care), suggesting that what may be a benign label (e.g. disc bulge) among many, might be dangerous/risky among the vulnerable.

When taking into consideration the cost, overmedicalization, and iatrogenic harm associated with the management of LBP, clinicians should strongly consider avoiding labels like arthritis, degeneration and disc bulge and instead consider using labels like an episode of back pain, lumbar sprain, or non-specific LBP when communicating with patients with LBP, where any specific structural cause needing further exploration has been reasonably excluded.

When considering oaths medical providers swear to “do no harm”, the act of removing labels like degeneration from LBP presentations (i.e. non-specific LBP) may play a very low risk, high reward role in helping to shift patients’ perspectives and enable them to feel more comfortable with accepting a non-invasive low risk medical treatment option for LBP.

+STUDY REFERENCE

O’Keeffe M, Ferreira G, Harris I, Darlow B, Buchbinder R, Traeger A, Zadro J, Herbert R, Thomas R, Belton J, Maher C (2022) Effect of diagnostic labelling on management intentions for non‐specific low back pain: a randomised scenario‐based experiment. European Journal of Pain. Published online.

SUPPORTING REFERENCE

1. Vos, T., Barber, R. M., Bell, B., Bertozzi-Villa, A., Biryukov, S., Bolliger, I., Dicker, D. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386(9995), 743-800.
2. Deyo, R. A., & Weinstein, J. N. (2001). Low back pain. N Engl J Med, 344(5), 363-370.
3. Bardin, L. D., King, P., & Maher, C. G. (2017). Diagnostic triage for low back pain: a practical approach for primary care. Medical Journal of Australia, 206(6), 268-273.