Betsy Q. Cliff / The Bulletin

Elliot Morrison, a 78-year-old Bend man, has had back problems for more than two decades. He's had injections to help him cope with the pain and three surgeries, including a fusion of some of his vertebrae.

His back is healthy now, Morrison says. But despite that a number of physicians have helped alleviate his pain, Morrison says his good condition now has much more to do with keeping his back strong through exercise. Morrison began working out with a trainer in 2008 and has continued to train several times a week ever since. Staying active and fit, he said, has helped more than anything.

“My wife and I go three times a week to (a training) studio,” he said. “I don't have any problems in my lower back and there's nothing I can't do.” Morrison said that after his most recent back surgery last summer, his surgeon told him the procedure was quicker and easier because he was in such good shape.

The state health department, in partnership with a nonprofit group, are hoping more Oregonians will take a lesson from Morrison. The nonprofit group recently launched a public health campaign, based on new state guidelines, to educate patients about the appropriate care for low back pain, including the importance of staying active.

In particular, the campaign stresses the need to stay active to alleviate pain rather than go straight to the physician's office. The goal is to reduce inappropriate use of screening and treatments in early, uncomplicated back pain.

According to statistics released as part of the campaign, more than a quarter of Oregonians who saw a physician for back pain received an imaging scan, despite these tests being clinically indicated only for certain, relatively rare instances.

“Sometimes expensive tests and X-rays really don't need to be done in the early weeks of back pain,” said Dr. Jeanene Smith, administrator of the office of Oregon Health Policy and Research at the Oregon Health Authority. “A large majority of back pain (cases) will resolve on their own.”

The campaign

The campaign is being run by the nonprofit Oregon Health Care Quality Corporation, which works to improve health care in the state and has partnered with the state on this initiative. The campaign, “Get Vertical! Don't Take Back Pain Lying Down,” launched this month with an online quiz and patient booklets distributed in physicians' offices.

It is based on guidelines issued by the state and released last fall. Development of the guidelines, geared toward primary care physicians, were directed by state health reform legislation passed in 2009.

The campaign emphasizes that most back pain is not caused by serious problems and there are things people can do at home to relieve low back pain before they see a physician. Most back pain, the booklet says, is caused by strained muscles or ligaments and does not require a doctor's attention.

“People just didn't know the right things to do when you had an episode of low back pain,” said Mylia Christensen, executive director at the Oregon Health Care Quality Corporation. “People used a lot of medical services for a condition that didn't require medical services.”

Instead of heading straight to a doctor's office, the campaign encourages people to use hot packs or over-the-counter pain relievers to alleviate pain, and try to stay active as much as possible. The campaign literature cites research studies showing that lying down to rest your back can actually prolong recovery.

It also cites some signs, including a history of cancer or back pain following an accident, which may indicate you do need to see a doctor.

With back pain, said Christensen, “an individual really has a lot they can do on the self-management side to increase their healing.”

The nonprofit ran focus groups before launching the campaign to see how much people really knew about managing back pain. For the majority of participants, Christensen said, the answer was clear: They don't know much.

People “had the expectation that there was no harm in imaging tests,” said Katrina Kahl, director of communications for the group. They were surprised, she said, to find out that not only can imaging tests be costly — about $1,000 to $1,500 for each test — they can also expose a person to significant radiation. Depending on the scan used and size of the person, a lumbar spine X-ray, according to the campaign literature, has the same dose of radiation as 65 chest X-rays, because of the amount of radiation needed to penetrate the soft tissue in that part of the body. A CT scan, according to the Food and Drug Administration, exposes a person to the same radiation as 75 chest X-rays.

And, Christensen said, “muscle issues are not going to show up in an X-ray or CT scan. Sometimes by doing those tests you just provoke more tests.”

Physician response

The campaign has targeted primary care physicians and plans to expand to specialists in the future. Here in Central Oregon, physicians said they thought the push for more conservative treatment was a good thing.

Central Oregon is notorious for having a high rate of spinal surgeries, one of the most aggressive ways to treat back pain. The area has one of the highest rates of spine surgery in the nation, according to Medicare data analyzed by a project through Dartmouth College, known as the Dartmouth Atlas.

“People in Central Oregon can be a little bit more impatient to resume their regular activity,” said Dr. May Fan, a family physician at Bend Memorial Clinic who has practiced in the area for more than 20 years. The new campaign advises people to wait a month before seeing their physician. But that, said Fan, “is a long time to wait if you are having back pain going down your leg.”

Fan said she hopes the public campaign would help people learn how to treat pain appropriately, and when it makes sense to do nothing. “We had to train the public not to expect an antibiotic with every cold and now people are starting to get it,” she said. “I think this will be similar.”

One of the biggest advantages in disseminating the guidelines to primary care providers might be to provide a ready guide for physicians, said Dr. David Kelly, a family physician at High Lakes Health Care who specializes in sports medicine. Primary care providers, he said, have to be “a jack of all trades and an expert in none of them.” Because back pain is commonly seen in a primary care practice, he said, certain habits of physicians, perhaps ordering imaging scans, may get ingrained even if they aren't supported by the best available evidence.

Kelly said he thought the dissemination and publicity around the new guidelines will make a big difference. There are other guidelines available that deal with low back pain, Kelly said, but “me going online to find the one that looks best, that could take hours or weeks.”

The state looked at 13 other guidelines in developing its recommendations and used a couple of well-respected guidelines in crafting its own. It also solicited input from physicians, insurers and others who deal with back issues, said Smith at the Oregon Health Authority.

Health insurance role

Right now, there is no enforcement behind the guidelines; physicians are free to follow or depart from the guidelines at will.

That could change, say physicians and policy makers. “If you look at the wave of the future,” said Kelly, “part of health care and health care reform is likely going to revolve around adherence to the guidelines.”

Kelly said he thinks physicians will be held accountable, by insurers and others, to making sure they are prescribing tests and treatments according to the best evidence available.

Smith said she didn't expect the state to issue regulations based on the guidelines but that insurance plans were already starting to use recommendations from the guidelines to try to lower costs associated with back pain. She cited several insurers that, for example, allowed patients to go directly to a physical therapist for back pain, rather than getting a physician referral. In at least one project, people who went directly to a physical therapist spent less time in the emergency room and missed fewer days of work, she said.

She said it was possible that health plans could also put up barriers to unnecessary care, requiring prior authorization for a test not indicated by evidence, for example, but had not seen any health plans do so yet.

The state intends to develop guidelines for at least 10 other conditions. Smith said policy groups are now in the process of figuring out which to tackle next. In the meantime, they hope that this first set will reduce unnecessary care in Oregon.

Back pain, “is very common,” said Smith. “It comes up on everybody's radar as something that has a lot of expensive treatments applied. We want to keep an eye on it.”

Do you know how to handle low back pain?

Take this quiz, developed by the Oregon Health Care Quality Corporation. More questions and explanations can be found on their website, www.partnerforqualitycare.org.

1. OK, now you're walking along, minding your own business and, suddenly — ouch! — there's that awful twinge of pain. At the first sign of lower back discomfort, you should:

A) Resume normal activities as soon as possible and see if the pain subsides after a few days.

B) Take a leave of absence from work and cancel all obligations for at least a month. You can never be too careful.

C) Go to the emergency room.

2. When you have low back pain, it feels like everything is out of whack. Which of these is not a great idea to do when your back is healing?

A) Taking a nonprescription pain reliever like aspirin or ibuprofen.

B) Taking a long, long break from your usual activities.

C) Using a hot pack or heating pad to help with pain.

3. When you have pain, it makes sense that you would want to, well, relieve it. Which are the best types of pain relievers to take for low back pain?

A) Stop whining: It's best to just tough it out without any kind of pain reliever.

B) Over-the-counter pain relievers are fine.

C) Prescription-strength medications.

4. Which of the following are typical warning signs that would necessitate calling your doctor?

A) Your back pain is from an accident or injury and just doesn't go away, ever.

B) My friends and family aren't being sympathetic enough.

C) I read something on the Internet that has got me all worried.

5. Imaging tests are rarely necessary if you're experiencing the most common type of low back pain: the kind that's caused by strain on muscles and ligaments. Why isn't it such a great idea to get these scans if they're not necessary?

A) They can make your back pain even worse.

B) X-ray and CT scans increase the risk of exposure to radiation while MRIs can pose a serious risk if you have metal objects or implants in your body.

C) Your scans might appear on Facebook or YouTube.

Answers: 1. A) ; 2. B); 3. B); 4. A); 5. B)

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