The first study, in the Journal of the American Medical Association,  examined acute LBP without the presence of radiculopathy in more than 5200 patients aged 65 years or older who went to their primary care physicians for this problem.¹ It sought to determine whether outcomes after 1 year would be better for patients who underwent diagnostic imaging (ie, CT, MRI, and plain x-ray films) during the first 6 weeks after the initial complaint than for those who did not undergo imaging during that period.

At the end of 1 year, no difference was found, on a measure of pain-related disability, between patients who underwent any of the tests during the initial period and those who hadn’t.

The second study is a meta-analysis of 14 trials with a total of more than 4800 patients with acute (less than 6 weeks’ duration) and subacute (6 to 12 weeks’ duration) LBP for whom the primary intervention was an educational program focused on reassurance.² The educational messages sought to: diminish concerns that the pain might represent a severe illness; reinforce the nonspecific nature of LPB and that extensive evaluations are unnecessary; and encourage patients to stay physically active.

The primary outcome measure was number of follow-up visits with the primary care physicians for the pain. Most of the studies lasted for a year and found that over this period, patients who participated in educational programs had a reduced number of visits compared with those who didn’t participate in the programs. The benefit appeared greater in those studies where it was the physician rather than a nurse or a physiotherapist who provided the education.

The third study compared symptom relief and functional improvements in patients with lumbar spinal stenosis who received physical therapy (PT) with those who had surgery for this problem.³ After 24 months, no differences between the two groups were found on either measure.

So what are the take home messages from these studies? I find 3.

The first and most obvious one is that for many cases of LBP we should be more judicious in the use of tests and surgical interventions. This supports recommendations based on earlier studies that demonstrated we don’t need to rush in every patient with LBP for radiographic studies. We know that in the absence of red flags such as signs of infection, recent trauma, unexplained weight loss, paralysis or paresis, or worse pain on lying down, it is highly unlikely that there is some severe medical process causing the pain that requires acute attention.

The second is that we need to talk with patients and give them a true picture of LBP to help alleviate their worst fears and concerns. I know from personal experience that many patients with LBP who have been seen by multiple physicians have never been provided with a straightforward discussion of what we know about LBP.

The third is that even where there appears to be an identifiable cause of the pain, as in a case of spinal stenosis, there are still many cases where patients do not need surgery to repair it in order to improve.

The overriding question is, if we know these conservative measures work, why aren’t they used more often?

Some may say about testing that physicians are afraid that if they don’t test, they will miss some serious underlying disorder, even though that would be extremely unlikely if they know to look for the red flags noted above.

Also, concern about overlooking  an underlying disease process doesn’t explain why physicians aren’t willing to spend more time educating their patients with LBP or why so many patients undergo surgery for LBP before having this or other conservative treatment modalities such as PT.

Unfortunately, I think the answer lies in how compensation for health care is handled in this country.