Physical Therapy Haven

I have been thinking about the current state of treatment for low back pain (LBP) recently.  If you haven’t already read, there have been several articles recently published in The Wall Street Journal that have addressed some concerning scenarios regarding spinal surgeries.  One editorial delves into the rising rate of spinal surgeries where another investigates royalties that some spinal surgeons may get when performing a surgery with a particular spinal implant.

There is no difference in the prevalence of back pain when comparing our country with other countries of the world.  However, the rate of people missing work and who are disabled secondary to LBP in the U.S is beyond what is seen elsewhere in the world. Furthermore, health care costs have sky rocketed within the past decade.  Martin et al¹ bring to light this fact stating that persons with spine problems in 2005 yielded a total estimated amount of $85.9 billion in expenditures. When comparing this amount to other significant pathologies, it was comparable to the expenditure for health care needs for cancer ($89 billion) and diabetes (98.1 billion). The fun doesn’t stop there.  Deyo et al² in 2009 further discuss over treating those with chronic LBP.  The authors found a 307% increase in use of lumbar magnetic resonance imaging (MRI) during a recent 12-year interval in the Medicare population, a 108% increase in opioid prescriptions from 1997 to 2004 and a 271% increase in epidural injections in Medicare claims during a recent 7 year interval.  What is wrong with this picture? 

Today, spinal fusion is a common surgical procedure used to provide structure stabilization to the spine in patients with LBP.  There are frightening statistics that foreshadow the ominous trend that we are experiencing in regards to spinal fusion.  Robertson and Jackson³ in 2004 found that patients with LBP who had spinal fusion, only 28.6% achieved good or excellent results on low back outcome measures and pain.  Earlier this year Nguyen et al⁴ found that only 26% (n = 188) of spinal fusion cases involving workers’ compensation subjects with LBP returned to work after two years, where 67% of nonsurgical controls had returned to work.  Furthermore, daily opioid use increased by 41% after surgery with 76% (n = 550) continuing the use of opioids.  This leads to the question: if poor long-term outcomes following spinal fusion are shown in the medical literature, why are so many people choosing this route?

It is imperative that we as physical therapists look at ourselves and ask:  are we feeding into this broken system?  Lutz et al⁵ describe how diagnostic trends have changed over the years.  In one aspect, it was neat to see how diagnostic trends changed throughout this past century, but at the same time, it was fascinating to read why. The authors report that technology spurred a diagnostic shift. Although this shift is remarkable, it seems to have hurt the medical field. The authors note that the chaos of low back pain has not changed with the improvements in technology—There is still 80% uncertainty in the etiology of low back pain, yet physicians are still searching for that one cause. Has technology turned the care for low back pain in the wrong direction? 

The authors make an excellent point about how major spine etiologies during the past century “have three features in common: They are focal, organic and can be visualized.”^{5 (pg. 1904)} The most important factor, I think, is the visualization piece. Many physicians will order an MRI to visualize what is “causing” the patient’s LBP when it has been reported that a pathoanatomic cause can be found for the patient's pain less than 10% of time.⁶ Why is the orthopedic medical community so obsessed with imaging when diagnosing LBP?

The finger is not only pointed at those that rely on imaging to diagnose LBP to guide practice, but those that reinforce the process. As PTs, it is imperative that we do not “fuel the fire” when it comes to a patient’s MRI results. How many times have we heard “the doctor told me I have a herniated…” or “I am in so much pain because I have degenerative changes in my low back?” We need to think about how to handle such situations and be mindful of the words we use to educate our patients. Think of words that may overall harm our patients and cause them to become fearful of movement.  As the chaos surrounding a pathoanatomic cause of back pain continues, we need to ask ourselves whether we are treating our patients or are we treating their MRI?

Overall, our profession has to get better when treating LBP.  The editorial from The Wall Street Journal by Julian Mincer shows how former New York Giants quarterback Phil Simms chose surgery, after a failed conservative approach that included physical therapy.  So, should one blame physicians for performing spinal fusion following physical therapy?  Are PTs doing enough to address the high prevalence of unstandardized care f LBP? Best clinical practice should and can start with us if the madness that envelops the treatment of LBP is ever going to be overcome.

blame Regardless, the madness that envelops the treatment of LBP needs to stop and needs to begin best clinical practice.

References

1.  Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656-64.

2.  Deyo, et al. Overtreating Chronic Back Pain: Time to Back Off? J Am Board Fam Med 2009;22:62– 68.

3.  Robertson PA & Jackson SA. Prospective assessment of outcomes improvement following fusion for low back pain. J Spinal Disord Tech. 2004; 17(3): 183-188.

4.  Nguyen TH, Randolph DC, Talmage J, Succop P, Travis R. Long-term Outcomes of Lumbar Fusion Among Workers' Compensation Subjects: A Historical Cohort Study. Spine (Phila Pa 1976). 2011 Feb 15;36(4):320-31.

5.  Lutz, G. K., M. Butzlaff, et al. (2003). Looking back on back pain: trial and error of diagnoses in the 20th century. Spine (Phila Pa 1976) 28(16): 1899-905.