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There has been a ton of press on the newly published article in the Journal of the American Medical Association (JAMA) discussing expenditures for back and neck pain from 1997-2005.  All the major newspapers have ran stories and thousands of blogs have discussed the topic. 

This article points out some of the major flaws in treating spine problems.  The increase in dollars spent on surgeries and drugs alone are enough to make you sick while reading the 9 pages.  For instance, narcotic analgesic use increased 423% between 1997-2004.  423%!  That’s ridiculous.  It’s no surprise that thousands to millions of individuals are addicted to drugs like oxycontin that do nothing but mask symptoms. 

Why are we (medical providers) so bad at treating some of these problems?  It’s really not all that complicated to figure out.  We have the wrong people – treating the wrong things.  Our system requires a person who hurts their back t0:

  1. See their family doc who is in no way prepared or equipped to evaluate or treat musculoskeletal complaints.  You may get some drugs and an x-ray.
  2. Receive referral to the Orthopedic specialist.  Wait about 2 weeks.  Receive a prescription pad full of anti-inflammatories, muscle relaxants, and maybe narcotics.  Heck, they may even throw in an MRI.  Lastly, after being told you have a “disc problem” or “arthritis” – they’ll send you to PT.
  3. Finally at the PT.  It’s been between 2 and 6 weeks since onset, but hey – you finally make it.  Uh oh – now there’s the whole “lack of standardization” issue in my beloved profession.  Depending on which PT you go to – you may bet evidence-based quality treatment or status quo, highly ineffective treatment.  Roll the dice. 

It’s been two months since onset and your pain is right where it was (for the most part) and you are starting to feel like there’s nothing you can really do.  Wonder what the bill for this scenario looks like?  God forbid you go on and they recommend surgery to “decompress and stabilize your spine”.  All of this and all you have is “non-specific low back pain” regardless of what they found on all the wasted imaging and in the ICD-9 book.

When will we ever learn?  How should this work?

  1. Individual hurts their back on Saturday.
  2. Monday morning, they walk into the Physical Therapy clinic (direct access is legal in most states you know)
  3. The Physical Therapist provides a thorough evaluation and screens for “red flags” that would require referral to another medical provider (we are trained and skilled at doing this you know).  The PT would then classify you based on clustering of signs and symptoms and treat you with matched interventions that could included directional preference exercises, stabilization exercises, manipulation, or even traction.  In a few short visits (and for a lot cheaper), you decrease your pain and disability by greater than 50% or more. 
  4. You are discharged with a do-it-yourself maintenance plan.  Back to work – back to life.

Sounds good huh?  So what’s the hold up.

It’s multifactorial.  It’s easy to throw the blame around and point the finger, but let’s look in the mirror first.  Physical therapy has an identity crisis.  We have allowed who we are and what we do to be confused as a bunch of “stuff” labeled as “physical therapy”.  The totally randomness of what many PT’s are doing across the country makes it nearly impossible at times to ensure a patient/client is getting quality care.  Clinicians are ignoring the evidence and choosing to practice based on tradition and comfort.  It’s time to standardize how we treat these problems.  Then we can be recognized as what we are – THE provider of choice for musculoskeletal conditions. 

Now to finger pointing.  Physicians are guilty of the same things mentioned above.  They consistently fail to recognize they simply aren’t prepared to treat these conditions.  Useless imaging and drugs (in most cases) comprise the majority of their involvement.  Not the mention the prevalence of spinal fusions that lack evidence for their use in many many cases (look at the failure rates).   In efforts to “hold on” as the gate-keepers, they fight PT’s direct access and professional protection like they’ll be out of jobs.  Who is hurt more?

I was going to save this space for Chiropractors but have chosen not to discuss their role.  To state it simply, you can see a chiro 37 times for modalities and repeated manipulation only to pay a huge bill and get no better.  But hey, the stories are good.  Just ask about the subluxation and how it can cause everything from radiculopathy to bed-wetting.

Any way, the fact remains that medical care in this country for back and neck pain isn’t where is should be.  It’s time for everyone to wake up and realize who are the go-to-providers (FIRST LINE) for musculoskeletal conditions. 

 As Dr. Tim Flynn says, “You have drugs, you have surgery, or you have us (PT)”. 

 FYI – Where do PT’s stack up as far as managing musculoskeletal conditions?  Physical Therapists AND physical therapy students rank higher than anyone outside of physicians trained as orthopedic specialists.  Who should be the “gate-keeper” for musculoskeletal care?  The family practictioner or physical therapists?  Leave the serious and complicated cases to the specialists.  Leave the rest (the majority) up to us.

 References:

Martin et al.  Expenditures and health status among adults with back and neck problems.  JAMA.  2008; 299(6):656-64.

Childs et al.  A description of physical therapists’ knowledge in managing musculoskeletal conditions.  BMC Musculoskeletal Disorders.  2005; 6:32.

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In the second post of the “Low Back Pain and You” series, I would like to discuss the use of imaging and the role it plays in the diagnosis and treatment of low back pain.  As I’ve discussed, imaging is often a part of the normal course of low back pain.  Primary care physicians and orthopaedic specialists are eager to order at least a radiograph (x-ray), yet rarely discuss the problems with their interpretation in terms of low back pain.

The fact of the matter is that medical imaging is overutilized and means little in most cases of low back pain.  In fact, their findings or interpretation usually fail to correlate with clinical signs and symptoms.  For example, an x-ray may show “no or mild degenerative changes” yet the patient have severe back pain.  Conversely, the x-ray may show a tremendous amount of degeneration in a patient with not a single complaint.

Why is this the case?  In many cases, the exact pathoanatomical cause of one’s LBP cannot be determined by any method.  Of course there are exceptions, acute trauma with fracture or a large herniated disc with clear nerve compression or cord changes are most likely the cause if present.

How about magnetic resonance imaging or MRI?  MRI’s are more advanced (and more expensive) imaging devices that give a more complete picture of the soft tissues (muscles, ligaments, tendons, etc) of the body.  In many cases of LBP, the MRI is ordered to examine the intervertebral discs.   While the advanced technology is nice and has improved identification of many pathologies and injuries (i.e. knee ligament ruptures, torn rotator cuffs, etc), they often lead to a false sense of knowledge in the case of LBP.  False positives have been reported in up to 30% of MRI cases.

So, why are imaging studies ordered so consistently?  Tradition and defensive medicine.  For years, the standard protocol has been to order an x-ray and/or MRI with the rationale that it’s better to be safe than sorry.  I would agree that safety (i.e. not missing a serious pathology) is vital.  I would like to also inform the public that medical literature has shown that Physical Therapists can screen these pathologies out or refer to appropriate practitioners without the expensive overutilization of imaging.

I certainly believe that imaging is both indicated and of value in certain cases, but not for every incidence of LBP.  The recent practice guidelines published by the American College of Physicians and the American Pain Society have taken one step to address this issue.  They recommend imaging studies only be conducted in patients when severe or progressive neurological conditions are present or suspected.  I hope the physicians are listening. 

Comments?

– Radiograph photo courtesy of www.ankleshop.com
– MRI photo courtesy of www.drkassicieh.com

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