Posts tagged low back pain
Impact Of Walking On Chronic Low Back Pain
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Low back pain remains the most common musculoskeletal diagnosis seen by primary care providers including Physical Therapists. While the majority of cases of low back pain are not serious in nature symptoms tend to be recurrent and can become chronic (> 3 months) if left untreated. As low back pain progresses from acute to chronic in nature changes in the both the peripheral and central nervous systems can occur leading to increased symptoms and loss of function. Patients with signs and symptoms consistent with nervous system changes are often prescribed pain science education and graded exercise to improve their symptoms and most importantly participation in life, work, and recreational activities. A recent review of the research examines the impact of walking vs. general exercise on patients with chronic low back pain.

Vanti and colleagues reviewed the available research on the effects of walking alone compared to exercise, as well as, the impact of the addition of walking to other forms of exercise (Disabil Rehabil. 2019). They reviewed 5 randomized controlled trials on the topic and make recommendations based off this evidence. In general, most forms of exercise including walking, showed a positive effect on a patient’s low back pain, fear of activity, and disability. Authors noted walking was not superior to other forms of exercise, but may be more easily implemented because of its’ ease of implementation compared to other forms of exercise. This study confirms prior research advocating for increasing the activity levels of patients with chronic back pain.

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Staying With One PT Provider Associated With Decreased Cost And Surgical Risk
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The statement, “Your treatment is only Physical Therapy if it is provided by Physical Therapists or Physical Therapist Assistants” rings true in today’s healthcare environment. Unfortunately, some high patient volume and Physician Owned Physical Therapy clinics in an effort to strengthen their bottom line utilize individuals such as technicians or aides to provide their treatments. These individuals lack the education, training, and most importantly licensure to safely and effectively provide care in a Physical Therapy clinic. The delegation of care from Physical Therapists to less educated and qualified personnel has also been shown to impact the outcomes for patients with low back pain.

In the journal Physical Therapy, researchers retrospectively analyzed the cost and clinical outcomes of patients with low back pain (Magel et al. 2018). Specifically, authors wanted to determine if the continuity of care (number of providers) was associated with low back pain outcomes and health care costs. Researchers found patients who experienced care from fewer Physical Therapy providers had a decreased likelihood of low back surgery. In addition, patients with greater continuity of care paid $800 less for their low back pain compared to those seeing greater numbers of providers. Although the study design cannot support a cause and effect relationship the evidence supports the use of fewer providers in patients with low back pain.

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Optimizing Glut Activation During The Crab Walk
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Strengthening the muscles of the hip, gluts, is a key component of rehabilitation for patients with low back pain, hip pain, and knee pain. These muscles help to optimize movement in the lower quarter improving joint mechanics and force distribution during life and recreational activities. In our Facebook posts, we have shown videos on optimizing the firing in the muscles on the back and side of the hips. These videos detail beginning, intermediate, and advanced exercises for each muscle group. One commonly utilized exercise is the crab walk which incorporates a lateral side stepping movement against a resistance band. A new research article highlights how placement of the band can optimize recruitment of the glut muscles.

Lewis and colleagues analyzed the activation of the glut muscles during a crab walk exercise using different elastic band positions (J Athletic Training. 2019). 22 healthy adults were asked to side step with the elastic band around the knees, ankles, and feet. During each 3 of the conditions, researchers analyzed EMG activity from the hip muscles including the TFL, gluteus medius, and gluteius maximus. As expected, increased glut work was found when the band was moved from the knees to the ankles lengthening the lever. Interestingly, placing the band around the feet increased the glut work without increasing the contribution from the TFL (often a muscle we try to utilize less during exercise). Thus, placing the band around the feet may be an optimal position to recruit the hip with less contributing from compensatory muscles.

Education Alone Does Not Improve Outcomes In Patients With Acute Low Back Pain
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In any profession, utilized interventions and methods change with incoming ideas and evidence. New concepts and treatments often advance ahead of clinical research trials aiming to support or refute their utilization. Within Physical Therapy, pain neuroscience education has become a popular topic of late. Education topics regarding the development and chronicity of persistent pain are being utilized to teach patients about their current symptoms. Although helpful, I often find some clinicians over utilize this intervention in place of other proven strategies in the management of patients with musculoskeletal pain. A recent study examined the impact of intensive pain education among patients with acute low back pain.

Traeger and colleagues published their findings on the impact of intensive low back pain education and self management strategies in the Journal of the American Medical Association Neurology (2018). Authors randomized 202 patients with acute low back pain to two, one hour sessions of either placebo education (active listening, without information or advice) or patient education (biopsychosocial aspects of pain, back pain self management). These education sessions were in addition to other first line treatments for low back pain including pain medication. Authors reported no improvement in pain outcomes between the education and active listening groups. Consistent with clinical management of acute low back pain, education should not be used in isolation but rather in conjunction with other proven treatments including spinal manipulation and exercise.

Reducing Your Risk Of Developing Low Back Pain
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Death and taxes are said to be the two certainties in life for adults, but Ben Franklin may have added low back pain given its’ current prevalence. Up to 90% of adults will report an episode of low back pain during their lifetimes. Fortunately, the vast majority of these episodes are not secondary to any serious pathology in the spine and respond well to low cost, conservative treatments including Physical Therapy interventions such as manual therapy and exercise interventions. In particular, strength training is one of the most effective treatment options to get you back to 100% after these acute low back pain episodes. To paraphrase again from Franklin, if you had an ounce of prevention new research reports it would be composed of exercise.

Researchers in the American Journal of Epidemiology conducted a review of the available evidence on the prevention of low back pain (Shiri et al. 2018). Authors reviewed 13 randomized controlled trials and 3 non randomized controlled trials for the analysis. They reported exercise alone reduced a person’s risk of developing low back pain by 33%. In addition, the severity and disability of the patient’s low back was also less in the active group compared to their sedentary peers. Authors recommended combining aerobic or stretching exercise with strength training, 2-3 days per week, for reducing a person’s risk of development of low back pain.

Physical Therapy First Reduces Opioid use, ER visits, and Healthcare Costs in patients with low back pain
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The evidence and momentum continue to build for seeing a Physical Therapist first for patients with low back pain.  Physical Therapists have continually been shown to be clinically and cost effective providers for low back pain conditions.  This approach, direct access to Physical Therapy, has been utilized by large hospital systems and Fortune 500 companies to both accelerate a patient's recovery and reduce health costs.  Studies report up to $1500 in cost savings when using this approach secondary to decreased utilization of health care services include office visits, medications, imaging, and surgery.

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A recent study followed patients with a recent onset of low back pain over a one year period (Frogner et al. Health Services Research. 2018).  Participants healthcare utilization was calculated based on whether they saw a Physical Therapist first, a Physical Therapy later, or were not prescribed Physical Therapy.  Consistent with the existing literature, patients who were seen by a Physical Therapist first had a 90% lower probability of being prescribed an opioid, as well as, lower rates of emergency department and imaging services.  The lower utilization of healthcare services were reflected in the significant cost savings found in the PT first group.

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