College of Family Physicians of Canada recommendation #1: Do not do imaging for lower back pain unless red flags are present.
Choosing Wisely Canada: Recall and describe a clinical encounter in which you were called on to choose wisely.
Dr. Elliot Lass: I had a virtual visit with a woman in her 40s, with a history of degenerative disk disease, for back pain. The patient, an office worker, had been working at home during the pandemic. While her back pain had previously been stable, she now presented with worsening, daily lower back pain. She was concerned she required urgent imaging.
CWC: In your exchange with the patient, how did you raise the need to choose wisely?
EL: History and physical examination: The number one tool we have is the history and physical examination. With a careful history we can determine if there are any red flags that warrant imaging, such as bowel or bladder dysfunction, history of malignancy, or fever. I tend to bring in patients with back pain for a physical examination as it helps me diagnose and counsel them appropriately. As the patient had been working from home, she had been working from the couch or kitchen table, without a proper ergonomic setup. Additionally, upon physical examination in the office, I was able to explain to the patient that imaging would likely not be beneficial in diagnosing her back pain.
Evidence-based tools: I also bring patients to the office to use instruments such as the CORE (Clinically Organized Relevant Exam) Back Tool. This tool, endorsed by the College of Family Physicians of Canada, provides an algorithm to help diagnose the cause of a patient’s back pain. I often turn my computer screen to the patient so they can see the tool, and I think it is reassuring for patients to know that we are basing our assessment on evidence.
With this tool I diagnosed the patient with pattern 1 discogenic back pain. We then discussed conservative management strategies and exercises. Additionally, we discussed practical strategies to improve her working environment such as ensuring she was working from a desk.
Education: I explain to patients that imaging is a tool to help diagnose serious pathologies, such as malignancy or infection, or to identify rare conditions requiring surgical intervention. As 50% of young adults without back pain have evidence of degenerative disk disease, I explain that imaging will likely not reveal the specific cause of their pain. With this patient, we discussed that if our management plan did not result in improvement by 6 weeks, we could consider imaging. Additionally, we discussed red and yellow flags that would warrant expedited imaging.
CWC: What are the key elements of the communication that made it a success?
EL: Understanding patient concerns: Determining what our patients are worried about is helpful in allaying their concerns. I ask patients about their feelings, ideas, function, and expectations (FIFE) in almost any encounter. In many cases patients are worried about malignancy, but this patient was worried about worsening of pre-existing degenerative disk disease. A careful examination reassured her that her work environment was likely the cause.
Providing resources: Giving patients reading material and using multimedia is often helpful in reassuring them. Having patient educational materials in primary care, including Choosing Wisely material, can help improve knowledge surrounding unnecessary care. With my patient, I used online images to explain some mechanics of discogenic back pain. I then printed off various exercises that tend to be helpful in managing back pain.
Providing an answer: What many patients want is an explanation for their pain and ways to control symptoms. Often this simple act is therapeutic. By using a systematic approach to help arrive at a diagnosis and providing the patient with a management plan and follow-up recommendations, she agreed that imaging was likely not needed. Her back pain resolved after implementing our plan.
This article first appeared in Canadian Family Physician. This interview was prepared by Dr. Aaron Jattan, Department of Family Medicine, University of Manitoba, for Choosing Wisely Canada.