What we say to patients with low back pain matters

- Jennifer Middleton, MD, MPH

I have recommendations for patients with benign low back pain (LBP) that I have repeated many times already in my career:

"It appears to just be a problem with the muscles. I don't think that it's anything more serious than that."

"Lift with your kness, not with your back."

"The abs and low back should work together to keep you upright.  A lot of people have weak abs, so getting the abs stronger can help back pain."

I always thought that I was giving good advice, but a study from the current issue of Annals of Family Medicine suggests otherwise.  This excellent qualitative study, titled "The Enduring Impact of What Clinicians Say to People With Low Back Pain," examined how patients interpret the phrases we physicians tell them about their LBP.

The researchers and participants of this entirely qualitative study were in New Zealand.  They included patients with both chronic and acute LBP that were at least 18 years old, had never had back surgery, and spoke English.  Almost all participants had seen a family doctor for their symptoms. The researchers conducted individual face-to-face interviews, and they continued recruiting participants until the findings from these interviews reached saturation, meaning that they were hearing no new themes or information.

Physicians hear "back" and think of all of the muscles, bones, and spinal cord, but this study found that when patients hear "back," they often only think "spine."  Physician advice to protect the back by lifting with the knees or strengthening the abs gave many of this study's participants the impression that their spine was vulnerable.  Because of this perceived vulnerability, several patients limited their activities, which likely worsened their symptoms since inactivity worsens most benign LBP.  Additionally, these back protection recommendations "may result in increased vigilance, worry, frustration, and guilt" for patients.

Happily, most participants responded positively when their physicians recommended that they stay active while recovering.  Physicians' "reassurance about prognosis or safety of movement could be very powerful," stated the researchers, as long as the participants had confidence in their physician; a history and exam perceived to be perfunctory and/or continued symptoms despite following the physician's advice both underminded this confidence.

This article will change my practice.  I'll make sure, in the future, to reinforce to patients that their spinal bones and cord are okay and not at risk from damage or injury.  I'll emphasize that back protection measures are not because I think their spine is at risk but instead to help reduce occurences.

I highly recommend reading this article in its entirety, as there are several more fascinating insights that space doesn't permit me to delve into further here.  AFP also published a helpful review of evaluation and treament of acute LBP last year, and there is also an AFP By Topic on Musculoskeletal Care if you'd like further reading.

Tackling the problem of too few family physicians

- Kenny Lin, MD, MPH

Researchers at the American Academy of Family Physicians' Robert Graham Center have estimated that the U.S. will require 52,000 additional primary care physicians by 2025 due to the effects of population growth, aging, and insurance expansion. Since it takes at least eleven years of post-secondary education to train a family physician, even a renewed surge of student interest in primary care careers is unlikely to meet this anticipated need. Another recent Graham Center study concluded that expanding the scope of practice of nurse practitioners and physician assistants would still result in an overall shortage of primary care clinicians.

This month's issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work "flow managers," establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.

Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.

Finally, Arthur Kellermann and colleagues propose creating the new occupation of "primary care technician," analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:

What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers. ... Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.

Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?

Just drinking water may not prevent another kidney stone

- Jennifer Middleton, MD, MPH

"I know what it is, doc - I've had stones lots of times before."
A patient of my colleague's said this to me a few weeks ago in the office, and, sure enough, the patient was correct.  2 days of colicky left flank pain and dysuria had, indeed, turned out to be recurrent nephrolithiasis.

My training regarding the counseling of these patients to prevent recurrence basically consisted of "drink water.  2 liters a day."  This patient had been doing that, yet still ended up with a stone again.  I vaguely recalled that there were some other things patients could try to reduce nephrolithiasis recurrences, but I couldn't remember anything specific.  I realized, then, that I had abdicated that decision making to the specialists who usually follow these patients.

One of this week's American Family Physician's POEMs discussed Fink et al's systematic review on this very topic.  The researchers examined 28 studies regarding prevention of recurrent nephrolithiasis using appropriate systematic review methodology and found that water works fine for preventing the second episode after an initial event.  But after the second episode, water by itself didn't do as well.  Participants with multiple stone episodes who added a thiazide diuretic, a citrate (for example, potassium citrate), or allopurinol to their 2 liters of water a day, though, had fewer recurrences.

This systematic review did a nice job of discussing how to tailor prevention based on the patient. Patients with calcium stones benefited from citrates and thiazides, regardless of their baseline calcium level. Allopurinol, of course, worked for patients with high serum uric acid levels or low urinary uric acid excretion.  Unfortunately, for struvite stones, findings were less promising; the reviewers looked at 3 studies that touted acetohydroxamic acid (AHA) as a preventive, but they felt that the strength of evidence from these only fair-quality trials was too low to recommend AHA at this time.  The reviewers also found that serum or urinary calcium levels didn't help to predict if a patient was more or less likely to have a recurrence, though serum uric acid levels can.

As a family doc, I want to be aware of what my specialist colleagues do, so I can appropriately reinforce their counseling and recommendations with our mutual patients.  I appreciated AFP's discussion of this systematic review and am very glad to have expanded my nephrolithiasis prevention toolkit.