Research Review By Dr. Joshua Plener©


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Date Posted:

March 2023

Study Title:

Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment


O’Keeffe M, Ferreira GE, Harris IA et al.

Author's Affiliations:

Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Australia; Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School; Department of Primary Healthcare and General Practice, University of Otago, Wellington, New Zealand

Publication Information:

European Journal of Pain 2022; 26(7): 1532-1545.

Background Information:

Within many chiropractic offices and existing clinical guidelines, non-specific low back pain (NS-LBP) is diagnosed when no specific structural cause can be identified (1, 2). However, there is some controversy regarding the use of this term, as opponents claim that it conveys the clinician doesn’t know what is wrong with the patient and that the term is a barrier to individualized care (3). As a result, clinicians commonly use other labels for low back pain in order to suggest a structural source of the pain such as disc bulge, degeneration, arthritis and lumbar strain to identify issues in the intervertebral discs, facet joints, lumbar ligaments and lumbar muscles (4). However, problems related to these terms stem from their low validity for identifying these potential structural sources of low back pain (5), the degree of clinical importance of these structural findings such as the degree of disc bulges in asymptomatic individuals (6), and the negative connotation that structural labels can carry (7).

It is well documented that patients want an explanation for their low back pain, but concerns arise regarding the vocabulary that clinicians use (7). For example, some vocabulary used may result in patients desiring unnecessary lumbar imaging, despite it not changing the eventual plan of management.

There is no literature on the impact of different diagnostic labels for low back pain. Therefore, the aim of this study was to investigate the effects of diagnostic labels for low back pain on patients’ perceived need for imaging. Secondary aims were to evaluate the effects of labelling on willingness to undergo surgery, beliefs about the need for a second opinion, perceived seriousness of low back pain, recovery expectations, and beliefs about the ability to engage with work and physical activities.

Pertinent Results:

Between October 12 and December 6, 2019 – 1375 participants were included in the analysis. There was difficulty recruiting participants with no lifetime history of LBP.

Participants who received the label “episode of back pain”, “lumbar sprain”, and “non-specific low back pain” were less likely to perceive the need for lumbar imaging compared to those receiving the labels “arthritis”, “degeneration” and “disc bulge”. An “episode of back pain” had the lowest perceived need for imaging in comparison to “arthritis”, “degeneration”, and “disc bulge” followed by “lumbar sprain” and “non-specific low back pain”.

Participants who received the labels “non-specific low back pain”, “lumbar sprain”, and “episode of back pain” were less willing to undergo surgery compared to those receiving the labels of “degeneration”, “disc bulge”, and “arthritis”. “Non-specific low back pain” consistently had the lowest perceived need for surgery, followed by “lumbar sprain” and “episode of back pain”.

“Lumbar sprain”, “episode of back pain” and “non-specific low back pain” participants were less likely to perceive the need for a second opinion, view their low back pain as serious, and had higher recovery expectations compared to “arthritis”, “degeneration”, and “disc bulge”.

All these differences noted above were more apparent in participants suffering from current low back pain with a history of seeking care.

There was no difference found between the groups regarding participants’ beliefs about physical activity and work being harmful.

Clinical Application & Conclusions:

This randomized experiment provides evidence that the diagnostic label provided to patients has an effect on the perceived need for imaging, surgery, and second opinions, as well as the perceived seriousness of low back pain and recovery expectation among individuals with and without low back pain. The impact of these labels appears to be most relevant for those at risk of a poor outcome; patients experiencing a current episode of LBP who have a history of care seeking.

The findings of this study align with other health conditions such as shoulder pain, as labels that medicalize a health condition or symptoms increase the intention for more aggressive treatment options. These findings are also apparent in qualitative research that describe patients perceiving certain labels as threatening and having a poorer outcome (8-10).

Ineffective medical tests and treatment for non-specific LBP is a significant issue, such as the use of unnecessary imaging and lumbar fusion surgery for arthritis which has shown no benefit over exercise (11). Clinical guidelines recommend advice and reassurance to help reduce the use of unnecessary tests and treatments for non-specific low back pain. This study found that certain diagnostic labels for low back pain can help reassure patients when communicating with them and can help positively shift patients perspectives regarding their opinions of their condition in order to improve guideline concordant management.

Study Methods:

A six-arm, parallel group superiority randomized experiment with blinded participants was conducted online. Three groups of participants were recruited through Qualtrics:
  1. Adults who have LBP and received normal treatment for their LBP at any time in their life;
  2. adults who have LBP and never received formal treatment for LBP; and
  3. adults who never experienced LBP in their lifetime.
An episode of LBP was defined as pain lasting for at least 24 hours which was assessed using the numeric rating scale. Participants were 18 years or older, able to read and write English and living in Australia, Canada or Ireland. These countries were chosen because each country has similar healthcare models.

All participants were provided with a scenario of attending a primary care clinician about LBP, describing the location of pain, triggering event and functional limitations. Participants were randomized to receive one of six diagnostic labels with explanations: 1) “you have a disc bulge”; 2) “you have degeneration of the spine”; 3) “you have arthritis of the spine”; 4) “you have a lumbar sprain”; 5) “you have non-specific low back pain”; or 6) “you have an episode of back pain”.

Disc bulge, degeneration and arthritis were chosen as they are common imaging findings in asymptomatic individuals and have been suggested to have potentially negative connotations. Lumbar sprain is commonly used by clinicians with no specific structural cause and patients perceive this as a diagnosis from an injury (9). Non-specific LBP was chosen as it’s the guideline recommended term and episode of back pain was chosen to describe a symptom of low back pain without attaching any structural descriptor.

All participants received the same reassurance from the primary care clinicians consisting of “I’m not worried that there is anything serious going on here. I think overall your outlook is good. Movement will help. The sooner we can get you back to your normal activity and work, the more likely your back pain is to get better.”

The primary outcome was the belief for needing imaging for low back pain assessed on an 11-point Likert scale, with secondary outcomes consisting of the willingness to undergo surgery for low back pain, belief in the need for a second opinion of low back pain, perceived seriousness of low back pain and recovery expectation, all assessed on an 11-point Likert scale.

A power calculation indicated that 1,296 participants were required to have an 80% power to detect a difference of 1 point in one of the six labels for belief about the need for imaging.

Study Strengths / Weaknesses:

  • This study used randomization, concealed allocation and sample size calculation to reduce bias.
  • Participants who were included had diverse viewpoints with and without low back pain, in addition to varying demographics and experiences of healthcare utilization for low back pain.
  • A consumer with experience of persistent non-specific low back pain helped co-design this study.
  • There was a large sample of participants recruited.
  • The results were based on a scenario and may differ compared to a real world situation.
  • The online recruitment may have selected participants who are more technologically inclined.

Additional References:

  1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344(5): 363-370.
  2. Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Medical Journal of Australia 2017; 206(6): 268-273.
  3. Bishop FL, Dima AL, Ngui J, et al. “Lovely pie in the sky plans”: a qualitative study of clinicians’ perspectives on guidelines for managing low back pain in primary care in England. Spine 2015; 40(23): 1842- 1850
  4. Kent P, Keating J. Do primary-care clinicians think that nonspecific low back pain is one condition? Spine 2004: 29(9): 1022-1031
  5. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European Spine Journal 2007; 16(10): 1539-1550
  6. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology 2015; 36(4): 811-816.
  7. Bogduk N. What's in a name? The labelling of back pain. The Medical Journal of Australia 2000; 173(8): 400-401.
  8. Darlow B, Dean S, Perry M, et al. Easy to harm, hard to heal: patient views about the back. Spine 2015; 40(11): 842-850
  9. Darlow B, Dowell A, Baxter GD, et al. The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine 2013; 11(6): 527-534.
  10. Sloan TJ, Walsh DA. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine 2010; 35(21): E1120-E1125.
  11. Mannion AF, Brox JI, Fairbank JC. Consensus at last! Long-term results of all randomized controlled trials show that fusion is no better than non-operative care in improving pain and disability in chronic low back pain. The Spine Journal 2016; 16(5): 588-590.

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