Remaking the Management of Chronic Low Back Pain

Imagine this scenario: A middle-aged man with chronic low back pain presents to a spine specialist after treatment with anti-inflammatory medications and poor pain control with low doses of opioids. He has already received multiple spine injections, with no lasting relief. The specialist notes that the patient has normal imaging studies and physical exam findings but is reluctant to challenge the patient’s assumption that his pain has a pathologic basis or his expectation for some sort of intervention. So another spine injection is ordered and the patient is sent on his way, likely to end up dissatisfied and to present to a different specialist in a few months. If an MRI is ordered, it’s likely to show some degenerative changes that may be blamed for the pain and may direct the patient toward spine surgery.

Scenarios like this are easy to imagine because they happen all the time across the United States. But Cleveland Clinic’s Neurological Institute wants to change that, and it’s undertaking an unprecedented pilot population health initiative for patients with (or at high risk of developing) chronic low back pain that it hopes may help reshape back pain management across the nation.

“Our initiative will promote functional outcomes rather than procedure-based care, such as spine surgeries, nerve blocks and opiate prescriptions,” explains Neurological Institute Chairman Andre Machado, MD, PhD. “It will focus the front end of care on rehabilitative efforts such as physical therapy and pain psychology to help individuals with chronic back pain recover and become active again.”

Time to reverse the order of care

“Today the point of entry to the healthcare system for a person with a persistent back pain problem is often a spine surgeon, regardless of the institution,” Dr. Machado continues. “Spine imaging is done and we too often misunderstand what it offers, failing to recognize that imaging findings that may suggest the cause of pain in some patients are also found in many other people who have no spine complaints. We, as a community of physicians, often leap to assume that operating or giving a spine block to address those findings will fix the chronic pain. When it doesn’t, pain rehabilitation is turned to as a rescue treatment.”

In the process, he adds, much unnecessary suffering and cost can be incurred — along with potential harm from the inherent risks of surgery and injections or if an opiate prescription is tried.

A big part of the solution is to reverse the order of care, Dr. Machado notes. “Pain rehabilitation, including pain psychology and physical therapy, must come first and be a common denominator to the treatment of all patients with chronic back pain. Some patients may ultimately also need a procedure to get back on the track of rehabilitation, but it should not be used as an initial step.”

How it will work

Under the new pilot project, patients who request an appointment for chronic back pain and meet eligibility criteria will be offered what the Neurological Institute believes is the gold standard: assessment by a team consisting of a physical therapist (PT) and a pain psychologist, in collaboration with medical and surgical spine specialists. This provider team will work to determine whether the patient’s back pain should be treated early on with an intervention or if the patient can undergo a course of physical therapy and pain psychology first — and perhaps obviate the need for any intervention.

Medical and surgical spine specialists will be readily available to the PT and pain psychologist to evaluate patients whenever needed. “This will ensure that we don’t miss, for example, myelopathy, motor deficits or cauda equina syndrome in a patient who comes in with primarily low back and/or leg pain but also has brisk reflexes and poor balance,” explains Center for Spine Health Co-Director Michael Steinmetz, MD, who is among the broad team of Neurological Institute clinicians designing the initiative.

A key aim will be to identify those patients who can benefit from pain rehabilitation alone and the presumably smaller group who require interventions such as blocks or surgery. “Even in the latter group, it will be understood that the intervention is not the final step of treatment but rather an intermediate step toward getting back on the path of pain rehabilitation and recovery of function, which is the common theme for all,” says Dr. Machado.

Multidisciplinary to the core

The initiative builds on the Cleveland Clinic Spine Care Path for acute and subacute back pain, which has been expanded to cover chronic back pain as well.

Like the care path, the new pilot is a highly multidisciplinary undertaking, with leadership from the Neurological Institute’s Center for Spine Health and Department of Physical Medicine and Rehabilitation as well as the pain psychologists in its Center for Neurological Restoration. “Attempting this is possible only because of the Neurological Institute’s distinctive organizational structure, which breaks down traditional departmental barriers to promote collaboration across disciplines and specialties,” says Dr. Machado. “It would be difficult to pull this off in a traditional organizational model.”

‘We need to do the right thing’

Even so, there are no illusions about the challenges involved, which include increased staffing — of PTs, psychologists and others — as well as inevitable questions regarding billing and logistics.

Then there’s the hurdle of gaining buy-in from patients and referring physicians. “Patients may be reluctant to hear they need to have their depression or some other psychological issue addressed before treatment of their back pain is likely to be successful,” notes Dr. Steinmetz. “And physicians may be sending patients with the expectation that they are ready for surgery when that’s not necessarily the case. But this initiative is based on the notion that we need to do the right thing. By identifying up front what patients’ true pathology is and then managing them accordingly, we believe outcomes will ultimately be better. If we can define how to do this well, the model can be replicated across the country.”

“It’s about delivering real value to patients rather than a quick fix,” Dr. Machado adds. “The idea is not original, but pulling it off in the realm of chronic back pain would be.”

Stay tuned for a future Consult QD post detailing the roles of the multidisciplinary clinical teams at the heart of this project.