Posts tagged low back pain
85% Reduction In Odds Of Receiving Opioid Medication If PT Are Used First For Low Back Pain

Early access to Physical Therapy services (direct access) has been previously shown to reduce a patient’s cost of care by up to $1500. In addition to its’ cost savings, direct access to Physical Therapy treatment has been shown to be a safe and effective short and long term treatment plan for patients with musculoskeletal pain. The greatest impact of this management model has been shown in patients with low back pain who face more costly and invasive treatment options including injections, imaging, surgery, and medications if they see a Physical Therapist later rather than sooner in their care. The dangers of these medications, in particular opiate pain medication, has come to the forefront in our country as a health crisis. A recent study highlights the impact direct access to Physical Therapy services can have on medication use in patients with low back pain.

Kazis and colleagues published a retrospective analysis of patients with low back pain to determine the impact early Physical Therapy on opiate medication use (BMJ open. 2019). Authors analyzed more than 200,000 patients to determine their health care utilization following an episode of low back pain. About half of all patients saw a primary care physician first (53%) and the others were seen by a conservative care provider including Physical Therapists. Patients who saw a PT first had a 85% and 74% decreased risk of receiving an opioid in the first 30 days and first year of their care, respectively. As expected, in states without direct access restrictions, such as Colorado, the impact was greater than more restrictive states. The authors concluded, “early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based non pharmaceutical interventions”.

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90% Of Patients With Back Pain Are Not Referred To Physical Therapy After Seeing Primary Care First

Low back pain, along with death and taxes, remains one of the certainties of life. This condition affects over 90% of Americans and is often benign, but painful, in nature. Currently spending on low back pain is over 100 billion dollars a year and much of this spending can be attributed to unnecessary and unwarranted tests and interventions including early imaging (x ray, MRI, CT scans), advanced procedures (injections, surgery) abnd office visits. Consistent with many musculoskeletal conditions, early treatment of acute low back pain accelerates a patient’s recovery and may be our best strategy at reducing health care spending and excessive treatments. Our previous blog posts have highlighted the benefits of direct access to Physical Therapy services or patient self referral including cost savings of $1000-1500 per episode of care. Despite the clinical and cost effective benefits of Physical Therapy, a recent study highlights the limitations of seeing a primary care physician first for low back pain.


Authors in the journal Spine analyzed over 170 million medical office visits for low back pain between 1997 and 2010 to determine health care utilization rates for this condition (Zheng et al. 2017). Authors found on average only 10% of patients with low back pain were referred to Physical Therapy after seeing a physician first and this rate remained stagnant over the study time period. Lower referral rates were found for patients covered by Medicare and Medicaid. Conversely, opiod prescriptions increased from 15% to 45% through the study’s 13 years of data collection. Authors found patients not referred to Physical Therapy were more likely to receive an opioid prescription.

Patients are encouraged to utilize direct access or advocate for a Physical Therapy referral for early treatment of their back pain symptoms.

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

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

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.