Posts in Back Injuries
Supervised Physical Therapy Superior To Home Exercise Program For Patients With Lumbar Stenosis
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Lumbar spinal stenosis is a narrowing of the bony canals in the spine which surround the nerves which supply our lower extremities. The condition is common among aging adults, > 60 years old, and can lead to symptoms such as single or bilateral leg pain, numbness, pins and needles, and/or weakness. Often leg symptoms are more frequent and severe than back symptoms. In our previous blogs we have discussed prior research papers indicating no long term (> 1 year) differences in outcomes between surgery and Physical Therapy for patients with lumbar spinal stenosis. Previous Physical Therapy approaches have focused on lumbar flexion exercises (ex. knees to chest) to create more space for the nerves, but more recent studies have shown benefits of manual therapy, strength training, and body weight supported treadmill walking. A recent research study highlights the importance of Physical Therapy compared to a home exercise program alone.

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Minetama and colleagues conducted a randomized controlled trial in the Spine Journal to compare the effectiveness of supervised Physical Therapy compared to a home exercise program for patients with spinal stenosis (2019). Authors randomized 86 patients with neurological claudication (symptoms in legs consistent with lumbar spine compression) to one of the two groups. The Physical Therapy group received treatment twice a week for 6 weeks while the home exercise group received a home program to be performed independently without supervision. Authors assessed function, gait, pain, and activity levels before and after the study. As expected superior outcomes on pain, gait, activity levels, and function were found among the supervised Physical Therapy group compared to those receiving a home exercise program.

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

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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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High Percentage of Positive MRI Findings Among High Performing Olympians
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In the absence of rare spine pathology the only abnormal low back MRI is a normal MRI.  After age 30 many of our spines will age and positive findings will become more common in patients with and without back pain.  MRIs have tremendous sensitivity and can find even the smallest amount of pathology, but their specificity is lacking in patients with low back pain.  Multiple studies have shown high rates of spinal pathology among asymptomatic groups of individuals.  A recent study highlighted the presence of spinal pathology among an elite group of athletes.  

Wasserman and colleagues retrospectively analyzed spinal MRIs of Olympic athletes from the 2016 Rio Summer Games (BMJ. 2018).  The authors reported 100 olympic athletes underwent a spinal MRI during the games and half of these high performing athletes were diagnosed with moderate to severe spinal disease.  Consistent with previous MRI studies, athletes over 30 years old had the highest rates of spinal disease on MRI.  The majority of athletes likely had positive findings on MRI before they had back pain and will have the same findings when their back pain is resolved.  Patients are encouraged to have their MRI findings read in light of their subjective and clinical examination to determine which spinal changes are due to age and which may be causing their current symptoms.

Physical Therapy Shown To Be Deterrent of Future LBP Flare Ups
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Death, taxes, and low back pain are three of the certainties of life with over 90% of individuals reporting low back pain at some point in their lives.  Our previous posts have described the ability of Physical Therapy to both accelerate a patient's recovery from low back pain and reduce its' risk of recurrence.  A recent study examined the factors that are correlated with a "flare up" or exacerbation of symptoms in patients with acute LBP.  

Authors studied 48 patients with low back pain (<3 months duration) and assessed for periods of either baseline symptoms or flare ups described as a period of increased pain lasting at least 2 hours (Suri, P et al. Spine. 2018).  Prolonged sitting, > 6 hours, was the only activity significantly associated with a flare up.  Patients who sat greater than 6 hours were 4 times more likely to have a flare up.  Mental health, including stress or depression, was also associated with a low back pain flare up.  The authors showed patients undergoing Physical Therapy treatments reported significantly less flare ups.

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How Does Low Back Pain Lead to Disability?
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Physical Therapy is an excellent choice for low back pain with numerous research articles supporting its' ability to rapidly reduce pain and disability.  Many interventions utilized in our Boulder Physical Therapy practice, including manipulation and exercise, are designed to prevent low back pain symptoms from being chronic or recurrent.  An interesting article was published identifying factors which play a role in the transition of low back pain to lost work and activity time.

Lee and colleagues conducted a review of the available literature on back and neck pain to determine the mechanisms behind the common life experience of low back pain and the less common outcome of disability (Pain 2015).  The authors reviewed 12 studies of close to 3000 patients with neck or back pain and found self efficacy levels, psychological distress, and fear explained the relationship between pain and disability.  Interestingly, other variables such as age, MRI findings, and function did not influence this relationship.  This study highlights the importance of how we frame, understand, and view our back pain symptoms.  Viewing our symptoms as a common, manageable occurrence may help reduce the transition from low back pain to lost work and play.