Using Telemedicine for Back Pain

Telehealth may be the next wave of relief efforts for spine patients

Jacob Ammentorp Lund/istock

Health consumers are becoming increasingly educated about their conditions and the treatments suggested to them by their doctors. While this trend certainly—and aptly—includes those people who live with neck or back pain, the net is cast much more widely than that.

Online and off, patients with all kinds of diagnoses are now doing more research, sharing more of their medical experiences outside the doctor’s office and summoning more courage to speak up for themselves when they feel undermined or coerced.

This may be out of necessity; the medical patient landscape, especially in the arena of spine pain, abounds with individuals who express having few, if any, options for relief.

For example, it’s not uncommon for people with back, neck, or spine-related leg or arm pain to report undergoing numerous and varied treatments, often more than once per treatment type. Such treatments may range from physical therapy and medication to injections and surgery.

Despite the breadth of options tried, though, many say they’ve emerged from their odyssey with less than satisfactory results.

Number-crunchers from the Agency for Healthcare Research Quality (AHRQ) looked at the relationship between spine care costs and improvement in backs and necks of the patients whose records they studied. While the overall average cost per patient came in at an exorbitant $6096 per patient for the year of 2005, the researchers could not justify those costs with corresponding pain reduction or physical functioning improvement.

 

Not only that, but in the eight years between 1997 and 2005, spine care fees increased by 65 percent, even though outcomes stayed pretty much the same. According to the AHRQ authors, "there was no improvement over this period in self-assessed health status, functional disability, work limitations, or social functioning among [survey] respondents with spine problems."

Another case in point is the use of diagnostic imaging tests—unnecessarily. A 2017 study published in JAMA Internal Medicine found that doctor’s offices that are associated with hospitals tend to overdo the use of MRI, X-rays, CT scans for a variety of diagnoses, including back pain.

In general, when imaging tests are given to patients unnecessarily (i.e., when the patient doesn't have nerve symptoms), they are considered to be “low-value.”

The study also found that hospital-associated medical providers made more referrals to specialists.

In case you didn’t know, along with inpatient services, hospital-associated doctor’s offices often provide outpatient care to people who live in nearby areas.

Does the Spine Care Industry Over-Medicalize Their Patients?

The movement towards savvier health consumerism may be attributed to Health 2.0, which started in the 2000s as enabling technologies for patients and their caretakers desiring to connect with others around medical concerns.

Nowadays, Healthgrades, Patients Like Me, Facebook groups dedicated to specific conditions or treatments, and other sites with similar missions are booming. There you will likely find physician ratings, knowledge exchange, cheerleading, and comradery.

In fact, many of these sites are quite successful in filling the gap between the diagnostic codes the doctor submits to insurance and patients’ lived experiences.

That said, keep in mind that often the people posting on these sites are not medical personnel, which means much of the knowledge you'll find is probably more opinion than fact.

Some of the organizations are also forging valuable connections between the development departments of drug and device manufacturers and their members. Many of the latter serve voraciously as patient advocates by speaking up for countless others with the same diagnosis.

Although the pressure to adopt a patient-facing medical model is mounting, many providers still prefer getting paid for the number of services rendered. Just the same, reams of data exist, and continue to be churned out, corroborating the notion that neck and back pain care is over-medicalized in America.

A 2013 study published in JAMA examined records for over 23,000 spine patients for the eleven years between1999 and 2010. The study found that prescriptions for NSAIDs and Tylenol decreased while prescriptions for narcotic pain relievers increased. Not only that, but physical therapy prescriptions only accounted for 20 percent of all the prescriptions by the doctors. 

Introducing Telemedicine and Telehealth

Promising technologies are on the horizon. The two new, related fields of telemedicine and telehealth are gaining steam, and not just for spine patients, but for everyone.

Also called direct to consumer medicine, telemedicine is the practice of medicine over a distance, with the use of voice, video, documents, and data. Telehealth, on the other hand, is a broader term that encompasses things like patient education, promotion, and prevention. Telemedicine differs from telehealth in that it's an actual clinical experience, complete with HIPPA compliance, diagnostic codes, treatments, and even in some cases, surgery. You might think of telehealth as things like apps, online weight loss program for health improvement, and the like.

Both fields are still in their infancy. But based on certain features, advocates believe they may ultimately prove instrumental in advancing the quality of care for everyone, and for extending much needed medical services to hard-to-reach patients. Areas with the greatest need include the rural U.S. and newly industrialized countries.

That said, a bird’s eye view of the burgeoning telemedicine field reveals that health outcomes resulting from the use of this delivery method are of varying quality. Providers who treat electronically do not always follow clinical guidelines, which are evidence based recommendations geared towards physicians and other practitioners. (To be fair, this is also true of providers who treat in house; while following clinical guidelines is likely an excellent idea that benefits both reputable providers and their patients, it’s not actually required by law.)

Add to this that not all electronic patients report being satisfied with their care, and you can see that more work needs to be done in the telemedicine and telehealth fields.

As an example, a 2017 published in JRSM Open found that chronic heart disease patients who saw their doctor via a telemedicine system reported only marginal satisfaction with the experience. Not only that, but the outcomes in this case were moderate, and the service failed to reach the patients who likely needed the care the most.

Another 2017 study, published in Front Pharmacology demonstrated that, for all its touted virtues, telemedicine may not be able to deliver the intended health improvement. The researchers were unable find enough evidence to recommend telemedicine for diabetics who need to control their glycemic index.

Telemedicine in the Spine Care Industry

But for people with neck and back pain, there’s a small glimmer of hope. If early research is any indication, electronic back and neck pain patients may fare a bit better than those who see other types of medical specialists through a web browser.

As of 2017, a number of researchers are recommending telemedicine sessions as adjuncts to in-person care. For example, a 2017 study published in the Journal of Physical Medicine and Rehabilitation found that remote neck pain patients achieved better pain relief, improved physical functioning and greater adherence to a home physical therapy exercise program than those who made the trip to see their doctor in person.

Another study, this one looking at telemedicine for low back pain, came up with similar results. The study was published in the April 2017 issue of Spine Journal.

From this research, it was gleaned that while telemedicine is not the be all, end all delivery model that e-Health advocates may want you to believe it is, at least in the spine care world, it does hold its own for reducing pain and/or disability in people with chronic low back pain.

That said, the authors note that as of 2017, telehealth is “understudied,” even as an adjunct to usual care.

One of the raging issues in the over-medicalization spine care debate centers around diagnostic imaging, asking questions like how many different types of “films” do you really need for a basic back strain? Or, should going to the doctor for back pain automatically necessitate the ordering of an MRI?

Evidence based clinical guidelines say no—that except when you have nerve symptoms that may point to a serious underlying problem, films and diagnostic tests are generally not necessary for a doctor to make a spine diagnosis.

In fact, a 2011 study published in the Annals of Internal Medicine, Chou, et al, concluded that routine imaging is not associated with clinically meaningful benefits. Yet many doctors continue to order them for their patients with mild to moderate spine pain.

Can telemedicine help?

Sorry, no. Although not much research has been attempted on this topic, one study, published in the March 2016 issue of Telemedicine and e-Health, did find that telemedicine spine doctors ordered a similar number of films as in-office doctors, which was between 79 and 88 percent of the patients seen.

A Word From Verywell

At least for now, we’re back to square one. Experts and lay people alike have known for decades that staying active is perhaps the biggest key to long term back health, even in the case of conditions that require medical care.

In particular, spinal stabilization and core strengthening have proven themselves over and over again in research studies.

For example, a 2001 study found that after two to three years, patients who relied on medical management alone were more than twice as likely to experience a recurrence of their problem as compared to those who embarked on an exercise program specifically designed for their condition in addition to medical management.

So, exercise instruction from a qualified provider who understands your particular back condition may still be your best bet for pain relief—whether you see them online or at the clinic.

Sources:

Chou, R., et. al. Diagnostic imaging for low back pain: advice for a high-value health care from the American College of Physicians. Ann Intern Med. Feb 2011. https://www.ncbi.nlm.nih.gov/pubmed/21282698

Dario, A. Effectiveness of Telehealth-based Interventions for Individuals with Low Back Pain. Spine. April 2071. https://www.fotoinc.com/news-updates/effectiveness-telehealth-low-back-pain

Gialanella, B., Home-Based Telemedicine in Patients with Chronic Neck Pain. American Journal of Physical Medicine & Rehabilitation: May 2017. http://journals.lww.com/ajpmr/Abstract/2017/05000/Home_Based_Telemedicine_in_Patients_with_Chronic.8.aspx

Hides, J., et. al. Long term effects of specific stabilizing exercises for first-episode low back pain. Spine. June 2001. https://www.ncbi.nlm.nih.gov/pubmed/11389408

Kruse, C., et. al. The effectiveness of telemedicine in the management of chronic heart disease - a systematic review. JRSM Open. March 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347273/

Lee, S., et. al. Telemedicine for the management of Glycemic Control and Clinical Outcomes of Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Front Pharmacol. May 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5447671/

Mafi, J., et. al. Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States. Jama Internal Med. June 2017. https://www.ncbi.nlm.nih.gov/pubmed/28395013

Mafi, J., et. al. worsening trends in the management and treatment of bnack pain. JAMA Intern Med. Sept. 2013. https://www.ncbi.nlm.nih.gov/pubmed/23896698

Uscher-Pines, L, et. al. Access and Quality of Care in Direct-to-Consumer Telemedicine. Telemedicine and e-Health. March 2016. http://online.liebertpub.com/doi/10.1089/tmj.2015.0079

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