What causes acute low back pain to become chronic? That's the question explored in a new study suggesting acute LBP patients shouldn't be going to primary care medical doctors for their pain. Here's why.
The study evaluated the care provided to 5,233 patients with acute LBP in 77 primary care practices. Among the potential factors leading to chronicity, the authors considered "nonconcordant" care, or care not consistent with established guidelines. Surprisingly, almost half (48%) of patients received at least one form of nonconcordant care.
The authors note: "[N]onconcordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary health care utilization."
Nonconcordant care was divided into three categories: pharmacologic, diagnostic and medical subspecialty referral. Almost 50% of patients received at least one form of nonconcordant care within the first 21 days– many for non-guideline-recommended medications such as opioids.
Patients were stratified based upon their likelihood of transitioning to chronic LBP: low, medium or high risk. Overall, about a third (32% unadjusted) transitioned from acute to chronic: approximately one fifth of low-risk patients, a third of medium-risk patients and almost half of high-risk patients.
A patient whose medical primary care medical doctor provided two or more forms of nonconcordant care was more likely to transition to chronic than a patient stratified in the medium-risk category. The nonconcordant actions of the MD effectively moved the patient from low risk (one in five chance of becoming chronic) to medium risk (one in three chance) or almost high risk (even chance). Overall, exposure to one, two or three forms of nonconcordant care increased the odds of transitioning to chronicity incrementally.
A student stands over a patient, needle poised. They have a “perfect” prescription: a textbook combination of points harvested from a lecture slide on chronic lower back pain. But as the needle meets the skin, the student hesitates - the symptom of a quiet habit that has taken hold of our profession. We routinely say we “prescribe” points. It sounds efficient. It echoes the authority of biomedical culture and fits neatly into the insurance field. But vocabulary is never neutral; repeated long enough, it dictates behavior.
Acupuncture can be highly effective in cases of nasal congestion so common in allergy presentations; so much so that I often treat such issues using acupuncture protocols alone. In cases of seasonal allergies with highly predictable causes such as obvious elevations of environmental allergens, I use a skeleton acupuncture prescription that can easily be fleshed out to target potential underlying patterns and effectively customized to the patient.
The field of acupuncture in the U.S. continues to grow in visibility, patient demand and clinical effectiveness. Yet behind the curtain, many acupuncturists are quietly struggling to keep their doors open. While the profession is rooted in centuries of healing tradition, modern economic pressures – particularly those driven by insurance limitations, low reimbursement rates and job-market saturation – are making it increasingly difficult for licensed acupuncturists to thrive.
