Takeaways:

• Most cases of low-back pain resolve in four weeks, but up to 77% recur without treatment.

• Three of four patients presenting to primary care with low-back pain are already in a recurring pain pattern.

• If recovery is considered the cessation of serious back pain for a year, less than half of patients recover spontaneously.

In a review published recently by The Lancet, Dr. Chris Maher and colleagues state, “The simple portrayal of the course of low back pain needs reconsideration.”¹ Dr. Maher refers to the view that most cases of acute, non-specific low back pain recover completely within four to six weeks. He qualifies this view as commonly held. Is this view oversimplified or a bad management guideline?

For older adults, data from a very large study suggests a new perspective.² Researchers followed 5,239 adults, age 65+, after their first primary care visit for low back pain (LBP). At three months, only 42% (a minority) experienced a 30% or greater improvement in pain. At one year, 65% still experienced disability within 30% of baseline. Seventy-seven percent reported that their back pain had not resolved at 12 months.

For the general population, Dr. Maher and colleagues recommend a treatment protocol that differentiates acute LBP from persistent LBP (> two weeks). Among patients presenting to primary care with persistent low back pain, only 42% report recovery at 12 months.³ For patients with persistent low back pain, Dr. Maher and colleagues recommend immediate referral for treatments such as exercise therapy and manual therapy.

Research suggests a better prognosis for younger patients presenting with acute LBP, but only by using a narrow definition of recovery.⁴ When defining recovery as a singular report of no pain or disability, 72% of adults with acute LBP and presenting to primary care report recovery within 12 months. That still leaves an important percentage of patients without recovery. That definition of recovery excludes recurrence within 12 months. Among patients who report recovery from acute LBP after their primary care visit, one third experience recurrence.⁵ If one were to define recovery as a cessation of significant pain or disability and no recurrence within 12 months, only 48% of patients presenting with acute LBP would be considered recovered. Dr. Maher and colleagues state that these recovery patterns provide caution against overestimating the likelihood of spontaneous recovery.

Dr. Maher and colleagues suggest that some patients presenting with acute LBP should receive treatment beyond advice and analgesics on day one, and others should be given two weeks to allow for spontaneous recovery. They recommend using risk prediction methods such as the 10-item Orebro Musculoskeletal Pain Screening Questionnaire⁶ to determine which patients will have earlier access to treatment.

It is noteworthy that 76% of patients presenting to primary care with acute LBP report having a previous episode of LBP.⁷ Most LBP cases labeled as acute are from patients already in a recurring pain pattern. This would suggest that the majority of acute LBP patients would qualify for non-pharmacological treatments such as exercise therapy and manual therapies on day one. If we hypothesize that all patients age 65+ receive physical therapy referrals on day one and all patients with LBP lasting greater than two weeks get a physical therapy referral on day one, we define a situation where most patients presenting to primary care with non-specific LBP receive treatment. Using the most modern evidence in LBP prognosis, only the most healthy patients presenting with non-specific LBP (a minority of patients) would be eligible for wait-and-see.

Specialized Treatment for Enhanced Outcomes

Back to Action invests in training, equipment, and facilities well beyond the standard training of physical therapists. This includes aquatic therapy, hand therapy, vestibular rehab, myofascial release, Mulligan technique, Maitland technique and much more. The availability of specialty approaches gives us greater opportunity for faster and better outcomes for all your patients.

References

1. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. The Lancet. 2016; 389 (10070): 736-747.
2. Rundell S, Sherman K, Heagerty P, et al. The clinical course of pain and function in older adults with a new primary care visit for back pain. J Am Geriatr Soc. 2015; 63 (3): 524-30.
3. Costa Lda C, Maher C, McAuley J, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ. 2009; 339: b3829.
4. Henschke N, Maher C, Refshauge K, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008; 337: a171.
5. Stanton T, Henschke N, Maher C, et al. After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine. 2008: 33: 2923-28.
6. Linton S, Nicholas M, MacDonald S. Development of a short form of the Orebro Musculoskeletal Pain Screening Questionnaire. Spine. 2011; 36: 1891-95.
7. Henschke N, Maher C, Refshauge K, et al. Characteristics of patients with acute low back pain presenting to primary care in Australia. Clin J Pain. 2009; 25: 5-11.
8. de Almeida AM, Demange MK, Sobrado MF, Rodrigues MB, Pedrinelli A, Hernandez AJ. Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial. The American Journal of Sports Medicine. 2012 Jun; 40 (6): 1282-8.

Takeaways

• Teaching patients self-care for low back pain does not save costs.

• Teaching self-care to patients does not achieve clinically important outcomes.

• Patients receiving supervised exercise plans prove 1.8 times more likely to achieve clinically significant improvement at 10 weeks.

• Patients with supervised therapeutic exercise rate much higher in patient satisfaction.

Nonspecific low back pain (LBP) ranks as one of the most common and costly musculoskeletal disorders, and the expense of LBP continues to rise. The majority of costs related to LBP can be attributed to recurrence and chronicity. One often-recommended solution for this problem is the teaching of self-care in the medical setting.^1-2 Advice as treatment for back pain persists despite the fact that a 2012 systematic review finds self-care alone unable to achieve clinically important results.³ Since the effects of self-care are clinically insignificant, is offering self-care without clinical supervision a lesser intervention than a referral to physical therapy? Recently, Physical Therapy and Rehabilitation published a randomized trial addressing this question.⁴

Researchers randomized 59 patients with chronic low back pain into a supervised group and a home exercise group. The home exercise group received consultation and training sessions at day one and two weeks later. In addition to advice on staying active and posture, they received personal and printed instructions in a fairly mainstream exercise therapy program. The program included stabilization exercises, cat-camel, spinal flexion / extension from quadruped position, curl-up exercises, “dead bug” exercises, the side-support exercise, etc. All participants received exercise logs. The supervised exercise group received the exact same treatment protocols, except they were scheduled for clinic appointments multiple times per week. At six-week follow-up, improvement in pain and physical function was significantly better among the patients receiving physical therapist supervision.

The researchers noted poor adherence rates to home exercise programs as demonstrated by the patients’ exercise logs. The home exercise patients showed 32% adherence compared to 36% in the supervised group. While neither adherence rate is sufficient, the supervised group had enough clinic visits to create the needed exercise frequency. A previous study confirms a correlation between degree of home exercise adherence and clinical outcomes,⁵ and the adherence rates in the present study are consistent with home exercise adherence rates observed previously.⁶ Researchers additionally hypothesize that supervision ensures correct performance of the exercises and the most efficient progression of difficulty.

The current study adds to the results of the recently published, first randomized trial on this subject.⁷ In that study, researchers randomized 300 patients to 16 different therapy practices. Similarly, those researchers found that patients receiving more supervision achieved a greater level of improvement. Statistically significant differences in favor of physical therapy persisted at the 52-week follow-up. For instance, at ten weeks, patients receiving physical therapy proved 1.8 times more likely to demonstrate clinically significant improvement in back pain ratings. On a one-to-four scale, median patient satisfaction in the physical therapy group was a four compared to a two in the advice group.

The current evidence suggests that offering good home exercise plans achieves lesser outcomes than referrals to physical therapy.

Our Therapists Average 9 Years’ Tenure Each

Experience, consistency, effectiveness – those are the hallmarks of the rehab your patients will receive at Back to Action. In addition to ample professional experience before joining our team, BTA therapists average nine years tenure each with Back to Action. This speaks to the quality of our workplace and the consistency you can count on when referring patients to Back to Action.

Please offer Back to Action to your patients.

References:

1. Maher C, Williams C. Managing low back pain in primary care. Aust Prescr. 2011; 34: 128-32.
2. Dagenais S, Tricco A, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010; 10: 514-29.
3. Oliveira V, Ferreira P, Maher C, et al. Effectiveness of self-management of low back pain: systematic review with meta-analysis. Arthritis Care & Research. 2012; 64 (11): 1739-1748.
4. Ammar T. A randomized comparison of supervised clinical exercise versus a home exer-cise program in patients with chronic low back pain. Physical Therapy and Rehabilitation. 2017 Aug; 4( 1): 7.
5. Jordan J, Holden M, Mason E, Foster N. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010; CD005956.
6. Holden M, Haywood K, Potia T, et al. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol). Syst Rev. 2014; 3: 10.
7. Ford J, Hahne A, Surkitt L, et al. Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. Br J Sports Med. 2016; 50: 237-245.

Articles in the Physician Article category are not intended for public consumption. They are news bulletins for clinicians licensed to refer to physical therapy. In reviewing this data, you agree that this is not medical advice and that medical advice should only be heeded after a proper assessment from a licensed healthcare professional.