Exercise, Empathy Helps Back Pain Patients in Primary Care

Heidi Splete

June 08, 2023

Treatment of chronic back pain remains a challenge for primary care physicians, and a new Cochrane Review confirms previous studies suggesting that analgesics and antidepressants fall short in terms of relief.

Data from another Cochrane Review support the value of exercise for chronic low back pain, although it is often underused, and the Food and Drug Administration's recent approval of a spinal cord stimulation device for chronic back pain opens the door for another alternative.

Regardless of treatment type, however, patients report that empathy and clear communication from their doctors go a long way in their satisfaction with pain management, according to another recent study.

Exercise helps when patients adhere

The objective of the Cochrane Review on "Exercise therapy for chronic low back pain" was to determine whether exercise improves pain and functioning for people with chronic low back pain, compared with no treatment, usual care, or other common treatments, corresponding author Jill Hayden, PhD, of Dalhousie University, Halifax, N.S., said in an interview.

When back pain is chronic, it is expensive in terms of health care costs and lost work hours, said Dr. Hayden. "Exercise is promoted in many guidelines and is often recommended for, and used by, people with chronic low back pain." However, "systematic reviews have found only small treatment effects, with considerable variation across individual trials."

The 2021 review is one of the largest in the Cochrane Library, and included 249 trials and 24,486 study participants. However, Dr. Hayden said she had been disappointed by the methodological limitations of many of the trials. "The field is saturated with small exercise trials, many of which suffer from poor planning, conduct, and reporting due to limited resources."

In the current review, "we found that exercise is likely to be effective for chronic low back pain. Overall, 3 months after the start of treatment, people receiving exercise treatment rated their pain an average of 15 points better on a scale of 0-100, and functional limitations were 7 points better, compared to people who had no treatment or usual care," said Dr. Hayden.

Barriers to the use of exercise to treat pain may include fear of movement on the part of patients, she noted.

"Although our related network meta-analysis found some differences between specific types of exercise, we found all exercise types are more effective than minimal treatment," she said. "People with chronic low back pain should be encouraged to do exercises that they enjoy and will do consistently to promote adherence."

Limitations of medications

Both the safety and effectiveness of analgesics and antidepressants for pain in general and back pain in particular have come under scrutiny in recent research. A study published online in the British Medical Journal of patients with acute low back pain found that, although some medications were associated with large reductions in pain intensity, compared with placebo, the quality of the studies was "low or very low confidence," according to a Medscape report on the findings.

This conclusion was supported in a large-scale analysis of the safety and effectiveness of antidepressants in chronic pain conditions, including back pain.

A new Cochrane Review led by a team of researchers in the United Kingdom found inadequate evidence to support the effectiveness of most antidepressants used for chronic pain, including amitriptyline, fluoxetine, citalopram, paroxetine, sertraline, and duloxetine.

"While chronic pain remains one of the top causes of daily disability worldwide, clinicians' choices at offering interventions are getting fewer, especially if they tend toward a medical model and want a pharmacological solution," corresponding author Tamar Pincus, PhD, of the University of Southampton (England), said in an interview. "We now know that opioids harm patients, and the evidence for common analgesics such as paracetamol and ibuprofen, for some conditions such as back pain, suggest they are not effective and might cause harm. This leaves clinicians with few options, and the most common prescription, supported by guidelines, is antidepressants."

The study found moderate evidence that duloxetine can reduce pain in the short term and improve physical activity and some evidence that milnacipran might also be effective, Dr. Pincus said. "For all other antidepressants, including the commonly prescribed amitriptyline, the evidence was poor. Of importance, the average length of trials was 10 weeks, so long-term effects for all antidepressants remain unknown, and side effects and adverse events were reported poorly, so we also don't know if any antidepressants are harmful."

The takeaway message for the management of back pain in particular? "If a clinician and a patient decide together that it would be a good idea to try an antidepressant to reduce pain, they should consider starting with duloxetine, the drug with supporting evidence," she said.

Physician attitude matters

Antidepressants may not have much impact on chronic pain, but a physician's empathy and support do, according to data from a registry study of more than 1,300 individuals.

Despite efforts and guidelines from multiple medical organizations to promote optimal pain management, "much remains unknown regarding how the patient-physician interaction affects the process of delivering medical care for chronic low back pain and, ultimately, patient satisfaction," John C. Licciardone, DO, of the University of North Texas Health Science Center, Fort Worth, and colleagues wrote in Annals of Family Medicine.

Previous studies have examined the relationship between clinical outcomes and patient satisfaction, but data on patient satisfaction with medical care for chronic low back pain specifically are limited, they said.

The researchers reviewed data from a national pain registry of adults aged 21-79 years that included self-reported measures of physician communication and empathy, prescribing data for opioids, and outcomes data for pain intensity, physical function, and health-related quality of life.

In a multivariate analysis, physician empathy and physician communication showed the strongest associations with patient satisfaction (P < .001).

The researchers found a negligible correlation between opioid prescription and perceived physician empathy and communication, "although current physician prescribing of opioids was also associated with patient satisfaction," they wrote.

"Our findings pertaining to physician empathy are intriguing because they do not necessarily involve a therapeutic alliance with the patient based on collaborative communication or the expectation of a therapeutic effect via pharmacotherapy," the researchers wrote .

The findings were limited by several factors including the cross-sectional design that prevented conclusions about cause and effect, the researchers noted. "It is possible that prior improvements in pain intensity, physical function, or [health-related quality of life] might have prompted participants to report more favorable ratings for physician empathy, physician communication, or patient satisfaction at registry enrollment." However, the study supports the view that patients with low back pain in particular value physicians who validate their concerns and symptoms, and who make an effort to communicate treatment plans clearly.

Back pain patients continue to challenge primary care

"Back pain is a major issue in U.S. health care, in part because too many people have tough physical jobs or longstanding injuries that become chronic," William Golden, MD, professor of medicine and public health at the University of Arkansas for Medical Sciences, Little Rock, said in an interview.

"There are no magic bullets for a lot of back pain patients, so empathy and support are key drivers," he noted. "Helping patients maximize functionality as opposed to seeking mythical cures is the stronger line of visit discussions, but that takes a bit of time and skill in interviewing.

"It is fairly well established that duloxetine is useful in pain management, especially when present with mood disorders, either primary or secondary to the back-related disability," said Dr. Golden. "Greater dissemination of its utility is probably useful, as is the side effect profile of the drug as well," given the "nasty discontinuation syndrome when the treatment is reduced or stopped."

Looking ahead, "more research is needed about microsurgery, namely for whom and for what anatomic presentations," said Dr. Golden. Other topics for further research include a better understanding about medical marijuana and pain management and its interactions and side effects with other opioids and muscle relaxants. "Polypharmacy is still an issue in this class of patient," and many of these patients are frustrated and angry "so the psychosocial skills of the PCP can be greatly tested as well," he said.

Empathy promotes patient adherence to treatment

The new opioid prescription guidelines have increased interest among clinicians in how to improve patient satisfaction with the care for back pain provided, Noel Deep, MD, said in an interview. "These studies address this concern and bring forth an important aspect of the physician-patient relationship, namely the human touch and empathy."

"I have been a strong proponent of the trust and relationship between a physician and patient; displaying empathy and increased and transparent communication between the physician and the patient has always resulted in better relationships and better outcomes for patients, especially those dealing with chronic health concerns," said Dr. Deep, who is a general internist in a multispecialty group practice with Aspirus Antigo (Wisc.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital, also in Antigo.

Potential barriers to effective pain management include beliefs and attitudes on the part of patients, Dr. Deep noted. "Physicians lacking adequate time to communicate effectively with the patient and describe nonopioid and nonsurgical interventions would be another potential barrier." Other issues include the time and effort, as well as cost, associated with interventions such as physical therapy and other nondrug and nonsurgical interventions. Issues with family and social support and health literacy are also potential barriers to pain management.

Clinical takeaways

Low back pain is one of the most common reasons for a visit in primary care and can be "chronic and debilitating," Grace Lin, MD, an internal medicine physician and primary care provider at the University of California, San Francisco, said in an interview.

"One issue with the Cochrane Review on exercise is that the studies on exercise were heterogeneous, so it's difficult to know whether there is a particular kind of exercise that would be most effective and should be recommended to patients," she said.

Furthermore, she said, "there is a physical therapist shortage in the U.S. I practice in a major city with a large health care system, and it can still take months to get an appointment with a physical therapist." Also, insurance coverage may limit which therapists a patient can see and how many visits they can have.

"On the clinician side, I think physicians need to be better informed about the evidence base for back pain treatment, namely that exercise is effective and that, long term, analgesics are not," Dr. Lin said. "This might decrease overprescription of ineffective analgesics and encourage more education about and referrals to physical therapy."

"Physicians should continue to educate patients that physical therapy is the first-line treatment for back pain and that pain medications are secondary," she said. "I think that analgesics can be effective for the short term to get people to a point where they feel well enough to do physical therapy. Duloxetine also appears to be moderately effective for chronic low back pain, in part because it may also help address coexisting depression and anxiety," but these options should be reserved for adjuncts to physical therapy for back pain.

The findings from the study on empathy and communication suggest that the main challenges to these behaviors are systemic, said Dr. Lin.

"Our health care system is not conducive to treating chronic back pain," she said. Primary care visits that last for 15 or 20 minutes are not long enough to diagnose and counsel patients on such a complex problem as chronic low back pain. Since back pain is usually not the only issue the primary care physician is dealing with during that visit, this can lead to patients feeling like their doctor isn't listening to them and doesn't care about their pain.

"We need to better understand the mechanisms by which people develop chronic, debilitating back pain," Dr. Lin said. "I think if we understood this better, more effective and targeted treatments, both pharmacological and nonpharmacological, could be developed."

The Annals of Family Medicine study received no outside funding, and the researchers had no financial conflicts to disclose. The Cochrane Reviews was supported by the National Institute for Health and Care Research's Health Technology Assessment program, and the authors had no financial conflicts to disclose. Dr. Golden and Dr. Deep had no financial conflicts to disclose and serve on the editorial advisory board of Internal Medicine News. Dr. Lin disclosed receiving research funding from the Institute for Clinical and Economic Review and the National Institutes of Health.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.


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