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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 this, the third post of the “Low Back Pain and You” series, we will discuss evidence-based interventions provided by Physical Therapists.  Hopefully, you will see why we should be the first person you see for your back pain and learn what to expect from you Physical Therapist.

Classification and Clinical Prediction Rules (CPR)

As we’ve discussed before, not all back pain is created equal.  So, why do many practitioners continue to treat every case of LBP with the same advice and the same medication?

Fortunately, Physical Therapists have developed a classification system that matches patients with appropriate and effective treatments.  The treatment-based classification system (Delitto et al, 1995) consists of categories based on the response of the patient to active motion.  These groups include active exercise with directional preference, traction, mobilization/manipulation, and stabilization.  In clinical studies, the TBC system has been shown to result in better outcomes than therapy based on clinical practice guidelines. (Fritz et al, 2003) 

More recently, Physical Therapists have developed clinical prediction rules to further identify patients who are most likely to benefit from certain treatments.  There are two clinical prediction rules related to low back pain.  These include the lumbar stabilization CPR (Hicks et al, 2005)and the manipulation CPR (Flynn et al, 2002).  Studies show significant improvements in patients who meet the clinical prediction rules and are treated with matched interventions.

Patients most likely to benefit from spinal stabilization exercises (74-97%  improvement in probability of success if patient fits 3 or more of the following):

  • Younger than 40 years old
  • Straight leg raise > 90 degrees
  • Positive prone instability test
  • Aberrant movement patterns
  • FABQ physical activity subscale < 9

Patients most likely to benefit from spinal manipulation ( presence of 4/5 resulted in an increased likelihood of success to 95%)

  • Duration of symptoms < 16 days
  • FABQ work subscale < 19
  • No symptoms below the knee
  • At least one hip with internal rotation motion > 35 degrees
  • At least one hypomobile lumbar segment

What does all this mean to you as a patient?  If your therapist is treating all back pain the same – find a new therapist.  Modalities such as hot packs, electrical stimulation, and ultrasound have been shown to provide little or no benefit in the treatment of low back pain.  Ask your Physical Therapist if they use classification systems or clinical prediction rules. 

To find a quality Physical Therapist in your area, click HERE

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