Physical Therapy for Low Back Pain, Meh...

[drusso]

http://jama.jamanetwork.com/article.aspx?articleid=2456165

Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back PainA Randomized Clinical Trial
Julie M. Fritz, PhD, PT1; John S. Magel, PhD, PT1,2; Molly McFadden, MS1; Carl Asche, PhD3; Anne Thackeray, PhD, PT1,2; Whitney Meier, DPT1; Gerard Brennan, PhD, PT2
[+] Author Affiliations
JAMA. 2015;314(14):1459-1467. doi:10.1001/jama.2015.11648.

Importance Low back pain (LBP) is common in primary care. Guidelines recommend delaying referrals for physical therapy.

Objective To evaluate whether early physical therapy (manipulation and exercise) is more effective than usual care in improving disability for patients with LBP fitting a decision rule.

Design, Setting, and Participants Randomized clinical trial with 220 participants recruited between March 2011 and November 2013. Participants with no LBP treatment in the past 6 months, aged 18 through 60 years (mean age, 37.4 years [SD, 10.3]), an Oswestry Disability Index (ODI) score of 20 or higher, symptom duration less than 16 days, and no symptoms distal to the knee in the past 72 hours were enrolled following a primary care visit.

Interventions All participants received education. Early physical therapy (n = 108) consisted of 4 physical therapy sessions. Usual care (n = 112) involved no additional interventions during the first 4 weeks.

Main Outcomes and Measures Primary outcome was change in the ODI score (range: 0-100; higher scores indicate greater disability; minimum clinically important difference, 6 points) at 3 months. Secondary outcomes included changes in the ODI score at 4-week and 1-year follow-up, and change in pain intensity, Pain Catastrophizing Scale (PCS) score, fear-avoidance beliefs, quality of life, patient-reported success, and health care utilization at 4-week, 3-month, and 1-year follow-up.

Results One-year follow-up was completed by 207 participants (94.1%). Using analysis of covariance, early physical therapy showed improvement relative to usual care in disability after 3 months (mean ODI score: early physical therapy group, 41.3 [95% CI, 38.7 to 44.0] at baseline to 6.6 [95% CI, 4.7 to 8.5] at 3 months; usual care group, 40.9 [95% CI, 38.6 to 43.1] at baseline to 9.8 [95% CI, 7.9 to 11.7] at 3 months; between-group difference, −3.2 [95% CI, −5.9 to −0.47], P = .02). A significant difference was found between groups for the ODI score after 4 weeks (between-group difference, −3.5 [95% CI, −6.8 to −0.08], P = .045]), but not at 1-year follow-up (between-group difference, −2.0 [95% CI, −5.0 to 1.0], P = .19). There was no improvement in pain intensity at 4-week, 3-month, or 1-year follow-up (between-group difference, −0.42 [95% CI, −0.90 to 0.02] at 4-week follow-up; −0.38 [95% CI, −0.84 to 0.09] at 3-month follow-up; and −0.17 [95% CI, −0.62 to 0.27] at 1-year follow-up). The PCS scores improved at 4 weeks and 3 months but not at 1-year follow-up (between-group difference, −2.7 [95% CI, −4.6 to −0.85] at 4-week follow-up; −2.2 [95% CI, −3.9 to −0.49] at 3-month follow-up; and −0.92 [95% CI, −2.7 to 0.61] at 1-year follow-up). There were no differences in health care utilization at any point.

Conclusions and Relevance Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.

Trial Registration clinicaltrials.gov Identifier: NCT01726803

---

Members don't see this ad.

 

[PainDrain]

4 weeks? Seriously?

 

[Aether2000]

In other words, early physical therapy for acute low back injury had no clinically significant effect over usual care, therefore early PT is a useless waste of health care dollars.

 

[Fiveoboy11]

In other words, early physical therapy for acute low back injury had no clinically significant effect over usual care, therefore early PT is a useless waste of health care dollars.

Your reasoning doesn't make sense as you inferred a lot from very little. You're supposed to infer little from a lot. This is one study, in which there were only 4 treatment sessions in the PT group over 3 weeks, and there was a reduction in disability compared to the education only group to 3 mo. I don't know how many patients I've seen meeting these inclusion criteria who've been given horrible advice from their doctor, and in the hospital who are on bed rest (which I ignore). How many cLBP patients are caused by the passivity that predominates medical practice? How many cLBP patients are caused by inactivity and/or fear/avoidance behavior?

From apta.org yesterday regarding this study:
Activity, Education, and Time May Play Biggest Role in Recovery From LBP
According to a new randomized clinical trial, early physical therapy may be related to minor short-term improvements in disability for individuals with low back pain (LBP), but the changes aren't really much different than what patients experience when they receive no treatment—provided those patients have been well-educated on the importance of staying as physically active as possible, that is.

The study analyzed data from 207 participants with recent-onset LBP who were divided into 2 groups—1 receiving an education on LBP followed by 4 sessions of physical therapy, and the other group receiving no further care after the education session. To assess improvement, authors of the study looked at patient-reported scores on the Oswestry Disability Index (ODI) at baseline, 4 weeks, 3 months, and 1 year after enrollment, as well as a few other measures, including the Pain Catastrophizing Scale (PCS) and Fear Avoidance Belief Questionnaires for physical activity and work. The study was published in JAMA, the journal of the American Medical Association (abstract only available for free).

All participants began by participating in what authors describe as an educational approach "likely beyond what typically occurs," with a session that educated them "about the favorable prognosis of LBP" and "advised [them] to remain as active as possible." Participants also received a book about back care and reviewed its contents with the researcher.

After that, the participant groups went their separate ways.

The physical therapy groups received sessions that began within 72 hours of enrollment in the trial, and were scheduled over 3 weeks, with 2 sessions in week 1, and a session each in weeks 2 and 3. The first session began with an assessment, followed by spinal manipulation, and instruction on spinal range-of-motion exercises to be performed at home. The second session included manipulation, review of exercises from the previous session, and instruction on trunk-strengthening exercises to be performed at home. The third and fourth sessions included exercise review and progression.

The "usual care" group receive no further intervention.

After 3 months—the primary outcome target of the researchers—the patients in the physical therapy group showed significant improvement in ODI scores (a 0-100 scale, with lower scores indicating less disability), with a drop in average scores from 41.3 to 6.6. This drop was better than the change recorded by the usual-care group, whose average score dropped from 40.9 to 9.8, but did not exceed the 6 point difference that researchers believe would have constituted a medically clinically important difference (MCID). Currently there is no single agreed-upon MCID score for the ODI.

Similar significant changes were seen at 4 weeks, and again, while these changes happened for both groups, the physical therapy group's change was more significant, albeit with a relatively modest between-group difference. By the end of 1 year, no between-group differences were found.

Secondary measures were a mixed bag, with some statistically significant outcomes favoring the physical therapy group slightly at 3 months (primarily in PCS scores and fear avoidance beliefs for work), but most others showing no between-group differences.

The study has received attention from media outlets including National Public Radio, which quoted lead author Julie Fritz, PT, PhD, FAPTA, as saying that "The average amount of improvement over 100 patients was small, but within that group, there were certainly patients that experienced large improvement and then others who didn't receive much benefit at all."
----------------------


And this study shows what many others have over and over: early physical therapy definitely does not waste, it saves money.

Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs.
Fritz JM, et al. J Eval Clin Pract. 2015.
Show full citation
Abstract
RATIONALE, AIMS AND OBJECTIVE:Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs.

METHODS: A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting.

RESULTS: 747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs (OR = 3.46, P = 0.001), advanced imaging (OR = 3.38, P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR = 4.76, P = 0.012) and LBP-related costs (standardized Β = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging (OR = 0.21, P = 0.001) or a surgeon visit (OR = 0.13, P = 0.005) and increased episode of care duration (standardized Β = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs (OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery.

CONCLUSIONS: Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.


I personally side with these physical therapy guidelines for LBP which are based on > 320 citations. The general guidelines are on page 46.The sub grouped guidelines are on pages 40-43:

http://www.orthopt.org/uploads/cont...Back_Pain_Guidelines___April_2012___JOSPT.pdf

 

[Aether2000]

My reasoning is sound. You inferred no referral to PT = confinement to bed. Not what I stated....activity is very important after the onset of acute low back pain providing there are no red flag signs. However this does not mean referring to very expensive physical therapy. This is a waste of health care dollars and I stand by my statement firmly. Just do yoga or pilates for a few bucks a week...

 

[Fiveoboy11]

My reasoning is sound. Your logic/reasoning is nonsense because I think you went backwards and inferred a lot from very little. Maybe your opinion fits your bias or agenda more than what all the evidence shows and what is best for the patient. Maybe you already had a certain practice pattern and this study supports or confirms it in your mind. The study was 4 treatment sessions over 3 wks (happens ~ never in real life) + education vs education alone shows no additional benefit after 1 yr = in your opinion that physical therapy is useless and expensive for acute low back pain. That's your reasoning. You inferred no referral to PT = confinement to bed. No I didn't. Not what I stated....activity is very important after the onset of acute low back pain providing there are no red flag signs. However this does not mean referring to very expensive physical therapy. I don't think every patient with acute LBP should be sent to a physical therapist. I never thought or said that. And for the proper patient it is helpful and cost effective. This is a waste of health care dollars and I stand by my statement firmly. Just do yoga or pilates for a few bucks a week...

Did you just imply yoga or Pilates can be substituted for physical therapy because it's cheaper? Why even do that if it's useless? I would favor Pilates of those two but a simple walking program as tolerated + resumption of ADL's as tolerated (minus inappropriate ones) + HEP + education + manual treatment as indicated is not interchangeable with it.

 

[Aether2000]

One of the greatest issues in medicine is the use of expensive therapies ordered by physicians that don't give a flip about costs nor about proven efficacy. Our health care system will simply not tolerate infinite increases without having repercussions, and the ACA has made it clear part of the cost increases will now be borne by reductions in physician's income. Knee jerk reactions by physicians ordering MRIs when not indicated, PT because they don't know what else to do or because it is a modus operandi in their practice that has not been examined for cost/benefit ratio, ordering non-generic medications because a buxom drug rep smiles at them, or doing procedures either not indicated or in their own out of network ASC are all reasons pain physicians are contributing to excess health care costs. With respect to PT, it does have a place but very limited in acute or chronic pain. PT is largely a luxury that is a late 20th and early 21st century concoction of an expensive specialty that did not exist in the practices of most physicians prior to those times and guess what- patients improved without PT. They used home exercise and stretches and a thing called common sense, something that is sorely lacking when every sports injury is automatically sent to PT for lets see......stretching, mobilization, iontophoresis, TENS, and strengthening exercises....most of which could be done at home with a simple printed instruction sheet.

Cochrane reviews struggle with PT interventions due to the fact that physical therapists don't know jack about the construct of or conduct of clinical trials. They report data as though this were the 1970s when a series of patients who improved with complete lack of control groups or the use of testing techniques that are also incorporated into their therapy but not the control groups, and with interventions/analysis with a very high provider bias and training bias. Most Cochrane conclusions regarding PT is that the profession almost exclusively conducts low level EBM trials that are not worth including in analysis. For this profession to validate itself as a useful (and cost effective) intervention, they must move into the 21st century with their studies, and physicians should not embrace a profession that cannot offer the same level of proof of efficacy and cost effectiveness as is required by physicians.

Physicians need to become educated regarding proven functional therapies so they can educate their patients, and at least try these at home, with follow up by the physician asking about patient progress, prior to sending patients to PT to the tune of $150/hour. And yes, cost does matter.

 

[Sheldon]

A Systematic Review to Assess Comparative Effectiveness Studies in Epidural Steroid Injections for Lumbar Spinal Stenosis and to Estimate Reimbursement Amounts

,
http://dx.doi.org/10.1016/j.pmrj.2013.05.012
Share on mendeleyShare on facebookShare on twitterShare on emailMore Sharing Services

• Abstract
• Full Text
• Images
• References

Objective
To systematically appraise published comparative effectiveness evidence (clinical and economic) of epidural steroid injections (ESI) for lumbar spinal stenosis and to estimate Medicare reimbursement amounts for ESI procedures.

Type
Systematic review.

Literature Survey
PubMed, Embase, and CINAHL were searched through August 2012 for key words that pertain to low back pain, spinal stenosis or sciatica, and epidural steroid injection. We used institutional and Medicare reimbursement amounts for our cost estimation. Articles published in English that assessed ESIs for adults with lumbar spinal stenosis versus a comparison intervention were included. Our search identified 146 unique articles, and 138 were excluded due to noncomparative study design, not having a study population with lumbar spinal stenosis, not having an appropriate outcome, or not being in English. We fully summarized 6 randomized controlled trials and 2 large observational studies.

Methodology
Randomized controlled trial articles were reviewed, and the study population, sample size, treatment groups, ESI dosage, ESI approaches, concomitant interventions, outcomes, and follow-up time were reported. Descriptive resource use estimates for ESIs were calculated with use of data from our institution during 2010 and Medicare-based reimbursement amounts.

Synthesis
ESIs or anesthetic injections alone resulted in better short-term improvement in walking distance compared with control injections. However, there were no longer-term differences. No differences between ESIs versus anesthetic in self-reported improvement in pain were reported. Transforaminal approaches had better improvement in pain scores (≤4 months) compared with interlaminar injections. Two observational studies indicated increased rates of lumbar ESI in Medicare beneficiaries. Our sample included 279 patients who received at least 1 ESI during 2010, with an estimated mean total outpatient reimbursement for one ESI procedure “event” to be $637, based on 2010 Medicare reimbursement amounts ($505 technical and $132 professional payments).

Conclusion
This systematic review of ESI for treating lumbar spinal stenosis found a limited amount of data that suggest that ESI is effective in some patients for improving select short-term outcomes, but results differed depending on study design, outcome measures used, and comparison groups evaluated. Overall, there are relatively few comparative clinical or economic studies for ESI procedures for lumbar spinal stenosis in adults, which indicated a need for additional evidence.

 

[Sheldon]

Interesting thread here. Let's be honest with ourselves though: CLBP is an iatrogenic problem and NOT one area of healthcare has the solution. If, say, the pain docs did, then Bill Gates would be working for them. If PT or chiro did, Bill Gates would be working for them too. As a PT, I see some really amazing rabbit holes patients are pulled in to by a medical establishment who treats the patient based off of MRI findings without an appropriate clinical examination, worker's comp patients who are kept out of work for ONE year, injection after injection without patient relief, the list goes on.

So, we can poo-poo one another all we want but what we should really be doing is inter-disciplinary management. If the patient is (-) UMN, (-) cauda equina, and (-) for multi-segmental and/or bilateral fatiguing weakness, let's get the patient moving and quit all the BS and turf battles.

Tim Flynn and others have done some great work on spinal surgery. If we are talking about PTs not being able to put out high quality research, his work is worth a real look. May speak of cost effectiveness too. I'm not sure what research Algosdoc is reading that is done by PTs, but it's not Flynn's work.

 

[101N]

Work disabling cLBP is a psychiatric problem/compensation problem.

 

[Aether2000]

Agree...in such cases pt is a waste of time. I looked at many cochrane studies....most threw out 98% of pt studies mainly due to lack of controls. PTs are 25 years behind in ebm. And they have doctorate degrees...

 

[101N]

There are some very savvy PTs out there. Many outside the US FFS system. Many are integrating a behavioral approach to chronic pain into their practices. Look up Jonathan Hill @ U. Keel, Steve George in Gainsville, or Lorimer Moseley in Australia. It was a PT - Keel - who came up with the STaRT Back tool.

 

[Aether2000]

And there are far more pts that are uninterested in chronic pain, uneducated in chronic pain, and turn over their patients to pt assistants while they drink coffee in the lounge. The profession as a whole does not replucate the gurus of pt experience and the profession as a whole offers insufficient proof of efficacy. I would much rather refer to yoga or pilates where the instructors do give a flip.

 

[101N]

I think we are a bigger problem than rogue PTs. Here is a link to the top IPM providers in my state.
Let's assume that these folks are seeing a lot of LBP and neck pain in their medicare audience. How
do you explain a 6x difference in collections services performed from top to bottom? Where is the data
on efficacy for the injections being provided? Where's the outrage about this 'mu-shu'?

https://projects.propublica.org/treatment/states/OR/specialties/207
http://graphics.wsj.com/medicare-billing/#/name=&special=Interventional Pain Management&city=&state=OR

Medicare paid us $160M in 2013 alone for 64483: https://projects.propublica.org/treatment/uniqservices/64483
https://projects.propublica.org/treatment/uniqservices/62311

PT's:
Top billing PT in OR: http://graphics.wsj.com/medicare-billing/#/name=&special=Physical Therapist&city=&state=OR
Therapeutic Exercise (97110): https://projects.propublica.org/treatment/uniqservices/97110
Manual Therapy (97140): https://projects.propublica.org/treatment/uniqservices/97140

 

[Aether2000]

I dont disagree with that at all. Got any suggestions on how to control them? Or perhaps are employees of a neuro group that feeds them 25 procedures a day....

 

[101N]

I know who those are at the top of the list in my state. They are not employees of OS/NS groups.
You can drill down through the data to ascertain what their business models are. For some
its injection mill, for others its a mixture of opioid/UDS mill and injections.

I don't think it's ethical to ignore this. But I'm not sure how we deal with it.

 

[lobelsteve]

I dont disagree with that at all. Got any suggestions on how to control them? Or perhaps are employees of a neuro group that feeds them 25 procedures a day....

Same old same old.
Pain foes single payor as a specialty.
Opiates limited to 2 weeks for non oain focs to rx. No procedures allowed unless you are on board. Includes scs trials, kypho, esi for outpatients, sij, mbb,rf. Must see 28 people per day. Salary, no incentive other than sovereign immunity. You become govt employee with benefits.

 

[101N]

I think most of us would probably agree that if we were to triage over-utilization in IPM a good place to
start would be pumps and discography. So...

Pumps: https://projects.propublica.org/treatment/uniqservices/62362
Discography: https://projects.propublica.org/treatment/uniqservices/62290

 

[drusso]

I know who those are at the top of the list in my state. They are not employees of OS/NS groups.
You can drill down through the data to ascertain what their business models are. For some
its injection mill, for others its a mixture of opioid/UDS mill and injections.

I don't think it's ethical to ignore this. But I'm not sure how we deal with it.

Really? How do you "drill down" through dog dookie administrative compilations and discern a business model? Absent denominator data, show me how you would prove that any practitioner is NOT a crook and instead doing an ethical mix of work that includes injections/med management, etc? I just don't how that is possible without knowing actual rates.

 

[101N]

Payments to providers are what you are referring to as 'dog dookie' administrative compilations. This is
a practice signature. If you're an outlier you need to explain where you are, not me.

You live in a glass house and yet you chose to call out physical therapists & chiropractors.

 

[drusso]

This is a practice signature. If you're an outlier you need to explain where you are, not me.

Oh, I see: Ex Cathedra evidence. Guilty until proven innocent. The Puritans had similar methods for detecting witches...

http://www.history.com/news/history-lists/7-bizarre-witch-trial-tests

 

[dunecat]

I didn't want to get into this and bump this thread, but I cannot help myself.

What's wrong with making a better living than most? Why does one have to "explain" themselves for making a very strong salary? As physicians, can we not just be happy that some of our colleagues are making a good living? He probably works hard, has built a great office model, and has many satisfied patients. Besides, he's not even close to the top, and I sincerely hope that MCR is less than 25% of his collections and that his collections - with more referrals - has improved from 2012/2013. I say this: good for him (and his patients)!

 

[Ducttape]

if a physician is providing ethical care and following accepted standards of care and billing appropriately, there is nothing wrong for someone to make more money. the aforementioned individual does not appear to be outside the norm for pain medicine.


i would, however, guess that, of those physicians who are in the top 1%, a pretty significant portion are doing something unethical....

 

[Aether2000]

Yes they are. We all know how finance of a pain practice works and the amount we are paid, overhead costs, etc. A person making over a million in after expense income is highly likely to be committing fraud in one way or another.

 

[SamellaCollins]

Absolutely right. I think the most appropriate solution of this problem is to do yoga on regular basis. If you are not used to it then take participate in yoga workshops. My recommendation for you is an upcoming yoga event named New York Triathlon Expo , you should join there , lectures will be there and coaches will also be there to guide you.

 

[willabeast]

Absolutely right. I think the most appropriate solution of this problem is to do yoga on regular basis. If you are not used to it then take participate in yoga workshops. My recommendation for you is an upcoming yoga event named New York Triathlon Expo , you should join there , lectures will be there and coaches will also be there to guide you.

i do not suggest yoga to my patients , one of the strangest backs i have ever seen was in the wife of a yoga instructor. it looked as if she had pulled her back apart. she must have had an unstable L spine to begin with?
also - a lot of injuries are associated with yoga. not as bad as crossfit, but i warn patients about them.
OTOH probably less injuries than a lot of other Rx's.

 

[Ducttape]

I do suggest yoga, but it depends on the type of yoga one is doing. generally speaking, I tell people to ask for Hatha, basic and well tolerated, slow paced and not stressful. Vinyasa maybe, depends on intensity. most commonly it is slow paced. Bikram is just basically hot sauna yoga. what you are seeing is probably an overreliance on very aggressive styles, such as Ashtanga...

better yet, Tai Chi (not the combat form)...

 

[freddydpt]

I have a Tai Chi handout that I give all patients who have exhausted their PT benefits... and some who have not. There are $5 classes in my region and it's like having a super cheap social PT session with deep breathing built in... can't beat it.

I go over Yoga positions with patients in more detail and avoid hyperflexion and extension positions and discuss some positions that may do more harm than good.

 

[Stim4me]

Pt's are as specialized as we are... A good sports PT is not the same as a geriatric or home care PT, pediatrics is another realm. Many Pilates and PT exercises overlap and are very helpful (esp for injured athletes). what I take from this study is that rushing people of for early PT because of insurance reasons or financial gain is questionable. As for cost, attack medical malpractice and defensive medicine. Recent study shows less lawsuits in your career if you order more tests... What does that tell you about the US medical system...

 

[Dr. Ice]

In the region that I practice, I have no choice but to put medicaid patients in PT even if it is against my better judgement. Medicaid will not authorize advanced imaging even if the patient's limb is falling off unless they have done 6-8 weeks of PT and sometimes even if they have a positive emg for acute radiculopathy, the MRI will still be put into review and then Im forced to do a peer to peer which takes 2 hours. I find it absurd that these patients, many of which are truly in acute pain have to go to a PT where all they will do is get stim for 20 minutes because they cant do anything else or because the therapists (like the physician) will get compensated peanuts for treatment. But this is what is coming to all of us..the law of the land..expansion of caid and forced compliance by all.

 

[Doctodd]

Share your yoga/pilates handouts plz

 

[clubdeac]

It's funny I used to tell a lot of my younger patients to do yoga. Then I did a groupon for a month and actually starting having low back pain. I only went about 8-10 times total so maybe that was just my body adjusting. I was a little surprised though when my back starting aching after every session. I think it was the damn cobra pose

 

[epidural man]

There is data that shows yoga does better than Pilates for low back pain...probably has something to do with the meditation piece.

Algos - you suggest education instead of sending to PT.
THAT made me laugh out loud.

I don't disagree - but most ya'all on here will brag about how many patients you can see in a day - like seeing 50 patients in a day is something spectacular and makes you a good physician or something. It makes you something....that's for sure.

If you see 30 patients a day, that is 15 min/patient.

There is no way you can get a history, do an exam, review imaging, discuss imaging and educate the patient about back pain and teach them what they need to do, then document - in 15 min.

Lorimer Mosley is a PT? I didn't know that. His TedX talk called "why we hurt" is awesome. I tell most of my patients to watch this, the "low back pain" on YouTube by docmikeevans, and that "Arthur's Inspiration" on YouTube.

 

[Aether2000]

PT is used as a nebulous therapy with a checkered history of effectiveness by insurers to justify other more expensive interventions including surgery, radio frequency, and imaging. There is no proof that such PT will help avoid these interventions in the majority of cases, and given the escalating cost of PT to the medical system, I cannot justify PT in the vast majority of cases. Whereas in sports medicine, PT may be effective, for chronic pain referral to PT is a perfunctory and completely unnecessary intermediate step before more definitive interventions are employed. Yes, education works. Getting down on the floor and demonstrating the exercises in addition to giving instruction sheets with the proper motivating verbiage, and continuing to reinforce exercise/movement/stretching with every visit is at least as effective as PT, esp. the lazy physical therapists who engage in passive modalities while they drink coffee in the lounge.

 

[Dr. Ice]

PT is used as a nebulous therapy with a checkered history of effectiveness by insurers to justify other more expensive interventions including surgery, radio frequency, and imaging. There is no proof that such PT will help avoid these interventions in the majority of cases, and given the escalating cost of PT to the medical system, I cannot justify PT in the vast majority of cases. Whereas in sports medicine, PT may be effective, for chronic pain referral to PT is a perfunctory and completely unnecessary intermediate step before more definitive interventions are employed. Yes, education works. Getting down on the floor and demonstrating the exercises in addition to giving instruction sheets with the proper motivating verbiage, and continuing to reinforce exercise/movement/stretching with every visit is at least as effective as PT, esp. the lazy physical therapists who engage in passive modalities while they drink coffee in the lounge.

Absolutely..the Medicaid patients who are required to get pt get stim for 10 minutes and are shown some stretching and that's what they have to go through for 6 weeks twice a week before I can even dare to order an mri..it's a freaking joke

 

[jesspt]

PT is used as a nebulous therapy with a checkered history of effectiveness by insurers to justify other more expensive interventions including surgery, radio frequency, and imaging. There is no proof that such PT will help avoid these interventions in the majority of cases, and given the escalating cost of PT to the medical system, I cannot justify PT in the vast majority of cases. Whereas in sports medicine, PT may be effective, for chronic pain referral to PT is a perfunctory and completely unnecessary intermediate step before more definitive interventions are employed. Yes, education works. Getting down on the floor and demonstrating the exercises in addition to giving instruction sheets with the proper motivating verbiage, and continuing to reinforce exercise/movement/stretching with every visit is at least as effective as PT, esp. the lazy physical therapists who engage in passive modalities while they drink coffee in the lounge.

Well, there is some data that shows an association between early referral to PT and reduced incidence of surgery, injection, and less frequent physician visits downstream.

And, I'm unaware of the trial that looked at physicians "Getting down on the floor and demonstrating the exercises in addition to giving instruction sheets with the proper motivating verbiage, and continuing to reinforce exercise/movement/stretching with every visit is at least as effective as PT," but not ruling out that it exists.

Yes, Lorimer Mosely is a PT, as is his co-author of the fantastic book "Explain Pain", David Butler. There are quite a few PTs/Physios who are doing some nice pain-related research, many who have been named in previous posts. I'd also add peter O'Sullivan and his group at www.pain-ed.com and the group at www.bodyinmind.org of which Mosely is a part.

 

[jonnylingo]

Interventional spine treatment is used as a nebulous therapy with a checkered history of effectiveness by insurers to justify other more expensive interventions including surgery, and imaging. There is no proof that such interventional spine treatment will help avoid these interventions in the majority of cases, and given the escalating cost of interventional spine treatment to the medical system, I cannot justify interventional spine treatment in the vast majority of cases.

Fixed it.
😉

 

[Aether2000]

Yes, there is some data....patients stratified to PT have less MRIs and less interventional pain since 1) PTs cannot order MRIs in the US 2) PTs cannot refer to interventional pain in many insurance schemes. Regarding PT vs interventional pain- I am unaware that was the point of this thread, but in many cases, I would agree that interventional pain suffers some of the same limitations that PT has. If you are a physical therapist, and all you have is a hammer-everything looks like a nail.

 

[SSdoc33]

PTs are not miracle workers. if there is an acute injury, particularly muscular, and the patient is motivated, PT is a very good option. acute HNP with spasms, RTC? sure.

chronic pain, stenosis, intra-articular disorders, FMS? not so much

 

[Dr. Ice]

PTs are not miracle workers. if there is an acute injury, particularly muscular, and the patient is motivated, PT is a very good option. acute HNP with spasms, RTC? sure.

chronic pain, stenosis, intra-articular disorders, FMS? not so much

They aren't..we know it and they know it. Problem is that it's often times mandated for no rhyme or reason to preclude other diagnostics/treatment as algos said. I've seen very good msk PTs who do great work, and I've seen others who probably shouldn't even be practicing. Yes one can say that about many interventionalists but that is not the point of this thread is it..

 

[SSdoc33]

They aren't..we know it and they know it. Problem is that it's often times mandated for no rhyme or reason to preclude other diagnostics/treatment as algos said. I've seen very good msk PTs who do great work, and I've seen others who probably shouldn't even be practicing. Yes one can say that about many interventionalists but that is not the point of this thread is it..

completely agree. to mandate it for every patient is done for purely financial, rather than medical reasons. it is irresponsible and a waste of resources to send many (all?) of these patients to PT, especially when we know they will get nothing out of it.

 

[GH253]

It isn't that proper rehabilitative exercise doesn't have therapeutic value for treating back pain, it's that the state of PT education is abysmal and most therapists don't have a clue what they're doing. The situation perfectly exemplifies the harm caused by professional licensing; rather than protecting the public from incompetent therapists, the government ensures that incompetent therapists are the only ones allowed to practice.

 

[GH253]

I have a Tai Chi handout that I give all patients who have exhausted their PT benefits... and some who have not. There are $5 classes in my region and it's like having a super cheap social PT session with deep breathing built in... can't beat it.

I go over Yoga positions with patients in more detail and avoid hyperflexion and extension positions and discuss some positions that may do more harm than good.

Yoga and Tai Chi are laughingstocks. They are mysticism, not science.

 

[Aether2000]

The bottom line is what do the systematic reviews show about effectiveness. With yoga, there is strong evidence of effectiveness, much more than for opioids, anticonvulsants, injections, spinal cord stimulation, or psych.
http://www.ncbi.nlm.nih.gov/pubmed/23246998
As for tai chi- moderate effectiveness evidence http://www.ncbi.nlm.nih.gov/pubmed/23876571

 

[freddydpt]

It isn't that proper rehabilitative exercise doesn't have therapeutic value for treating back pain, it's that the state of PT education is abysmal and most therapists don't have a clue what they're doing. The situation perfectly exemplifies the harm caused by professional licensing; rather than protecting the public from incompetent therapists, the government ensures that incompetent therapists are the only ones allowed to practice.

I would love to hear a more detailed explanation. Please elaborate.

 

[jesspt]

I would love to hear a more detailed explanation. Please elaborate.

I would love to hear a more detailed explanation. Please elaborate.

Yeah, I'm all ears.

 

[Astharia]

Yoga and Tai Chi are laughingstocks. They are mysticism, not science.

I don't know anything about Tai Chi, but I'm pretty sure that standing in a low squat with your arms held out for a period of time, uses a specific set of muscles and strengthens them. That's not hard science to understand. Maybe the idea is mysticism, but the activity sure as hell helps. And as someone that's overweight and working on it, Yoga and Tai Chi are good practices compared to sitting at a desk all day doing nothing.

 

[Stim4me]

I don't know anything about Tai Chi, but I'm pretty sure that standing in a low squat with your arms held out for a period of time, uses a specific set of muscles and strengthens them. That's not hard science to understand. Maybe the idea is mysticism, but the activity sure as hell helps. And as someone that's overweight and working on it, Yoga and Tai Chi are good practices compared to sitting at a desk all day doing nothing.

Try the veradesk, elevating desk, would help alleviate psi on your lumbar spine. Tai chi, Pilates, and yoga have some literature suggesting clinical benefit. Any activity is important overall...

 

[willabeast]

IMHO nothing (no treatment) for acute low back pain has ever been shown to be better than walking. Walking is also very safe.

Simplicity is the law of nature for men as well as for flowers.
 Henry David Thoreau  — Journal, 29 February 1852

 

[Astharia]

Try the veradesk, elevating desk, would help alleviate psi on your lumbar spine. Tai chi, Pilates, and yoga have some literature suggesting clinical benefit. Any activity is important overall...

Agreed. Right now, I try to take breaks when I sit at my desk at home, and do some light yoga poses in the office. I have major SI joint dysfunction after having 3 kids, I've done physical therapy for it from 6 months- 1 year after my last, and it helped a ton, enough to get me functional again. I'm trying walking and light yoga because I know my weight is likely the biggest factor to the problem. Plus, I feel like it may be hard to take someone seriously about going into medicine if they're 60lbs overweight.