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  • Experts: It's Time to Act on the Evidence for Low Back Pain

    Recent features on Good Morning America and WebMD aside, the idea that low back pain (LBP) is best managed through nondrug, nonsurgical approaches isn't exactly news to physical therapists (PTs) and physical therapist assistant (PTAs). What would be news is if health care systems and providers widely accepted that reality and began taking steps to apply evidence to practice and payment.

    The latest rise in media attention on LBP was sparked by a recent series of articles published in The Lancet (free registration required) that highlighted the lack of adherence to clinical practice guidelines advocating "self-management, physical and psychological therapies" as first-line treatment for LBP. It's a disconnect that authors believe deserves immediate attention, given that LBP is the leading cause of disability worldwide, and is a condition that is increasing more rapidly in low-income and middle-income countries, according to the Lancet articles.

    The problem, according to the authors, is that despite the evidence, many providers—including some PTs—still recommend rest and time off work, and the use of drugs and surgery is more prevalent than it should be.

    "The message here is the critical need to close the evidence-practice gap across all aspects of spine care," said Julie Fritz, PT, PhD, FAPTA, a co-author of the study. "This message applies to physical therapy as [much as] it does to all other providers who may continue to advocate for overuse of ineffective treatments such as opioids and imaging. Professional stewardship demands that we examine our own profession even as we critique aspects of practice in other professions."

    By way of example, the Lancet articles point out that physical modalities such as transcutaneous electrical stimulation (TENS) or ultrasound have been found to be ineffective but often are recommended by PTs in many countries. One study cited found that 75% of US PTs used lumbar traction, and 38% of Swedish PTs used TENS; another cited study from India reported that one-third of PTs preferred physical modalities as first-line interventions.

    The gap is even more prevalent when it comes to the use of psychological therapies in combination with physical modalities—an approach that has proven to be effective. According to the Lancet articles, a recent study found that just 8.4% of patients with LBP in the US were prescribed cognitive behavioral therapy.

    "Care for patients with chronic conditions such as low back pain is inherently multidisciplinary," says Fritz. "There are opportunities for innovative care delivery models that integrate mental and physical health care providers, and PTs should welcome the chance to be a part of these programs. Triaging patients based on their mental health needs should be a part of physical therapist practice in the same manner as triage for physical needs."

    According to the Lancet authors, the problem isn't just about lack of action by providers—patient barriers to proper care for LBP also play a role in the problem on a worldwide scale. Authors advocate changes from health care systems that often reimburse surgery or medication over other interventions to systems that reimburse only evidence-backed treatments. Experts also recommend the development of "clear care pathways, referral, funding, and information technology systems" that would help clinicians deliver the most effective care at the right time.

    "All countries seem to be struggling with the same fundamental problem of closing the evidence-practice gap for patients with low back pain but there are lessons to be learned," Fritz observes. "Payment models in other countries are quite different from our fee-for-service model in the United States. These payment models certainly influence the overutilization of high-cost, low-value care such as back surgery. Other countries are also beginning to modify the basic care pathways for musculoskeletal pain conditions, with greater opportunity for physical therapists to serve as first-contact providers. Efforts in the Netherlands and United Kingdom, among others, bear watching."

    Comments

    • https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-15-416 Would appreciate viewpoints considering the above llnk recently published. As a profession do we know where this is going?

      Posted by Rob capri on 3/31/2018 7:09 AM

    • In my lifetime I have treated approximate 7-8,000 cases of low back pain. The sign most common to all is a trigger point at the posterior inferior iliac spine. The singular diagnosis is common to these is the sacral x axis syndrome. This is caused by an anterior shift in the line of gravity with an anterior innominate rotation on the sacral x axis. Symptoms are immediately relieved with a manual posterior innominate rotation.

      Posted by Richard DonTigny, PT on 4/4/2018 6:28 PM

    • Richard DonTigny, PT is correct: Realigning the pelvis with a manual posterior innominate rotation (preferably via self-mobilization) is the most effective technique for relieving low back pain. After all, gravity teaches us that when the sacrum is unstable the lumbar spine is also unstable. For lasting results, teach the patient how to maintain alignment by re-integrating the small, joint stabilizing muscles (transversus abdominis and lumbar multifidi). Motor control deficits and low endurance in the "local" muscles are the problems, NOT strength deficits. In 1998, 10 minutes of instruction by Richard changed the course of my personal and professional life. Richard, my patients and I thank you.

      Posted by David Toivainen, PT on 4/7/2018 11:13 AM

    • The evidence is there. Some people don't want to admit that but it is. Determining directional preference and treating accordingly was the strongest group within the TBC approach and it's the hallmark of.......MDT. MDT therapists have known for years that finding directional preference and ruling whether LBP is mechanical or not has been the most reliable way and they have the literature to prove it. Look at the bibliography of any MDT course and you'll see the evidence. Most of the evidence that states MDT does NOT make a difference is poorly done research as well. There's plenty of that out there too unfortunately but look at the research methods and you'll usually see why.

      Posted by Tom Eberle, PT, OCS on 9/2/2018 12:41 AM

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