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A Long Way to Go: Practice Patterns and Evidence in Chronic Low Back Pain Care

Carey, Timothy S. MD, MPH; Freburger, Janet K. PT, PhD; Holmes, George M. PhD; Castel, Liana PhD; Darter, Jane BS; Agans, Robert PhD; Kalsbeek, William PhD; Jackman, Anne MSW

doi: 10.1097/BRS.0b013e31819792b0
Health Services Research

Study Design. A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006.

Objective. The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition.

Summary of Background Data. Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer.

Methods. Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews.

Results. Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state.

Conclusion. Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

A statewide survey of individuals with chronic low back pain was conducted, examining utilization of care and the evidence base for the efficacy for those tests and treatments. Several treatments appeared to be underutilized, including treatment of depression and use of exercise. Overused tests and treatments included extensive use of multiple advanced imaging tests, muscle relaxants, traction, corsets, and TENS units.

From the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC.

Acknowledgment date: July 23, 2008. Revision date: September 17, 2008. Acceptance date: October 9, 2008.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) R01 AR051970, National Research Service Award (NRSA) Institutional Training Grant from the Agency for Healthcare Research and Quality (T32 HS000032).

Address correspondence and reprint requests to Timothy S. Carey, MD, MPH, 725 Airport Rd, CB 7590, Chapel Hill, NC 27599-7590; E-mail:;

© 2009 Lippincott Williams & Wilkins, Inc.