Jill Murphy, DPT, LAT, CSCS
As a physical therapist who specializes in the evaluation and treatment of the spine, the majority of the patients who are referred to my clinic have had back pain for a year or more. There is also the segment of patients who have a more recent flare of chronic low back pain, meaning their pain has not been continuous for the past 12 months. However, the overwhelming majority of patients that I see every day are battling not only local, long-term tissue irritation, changes, and compensatory patterns that develop when back pain becomes chronic, but also changes in the nervous system that make the brain more hyper-sensitive to feeling pain in the affected area compared to a patient without low back pain. It is very rewarding to see this type of patient succeed in reaching their goals, but it does take a lot of time, focus, dedication, and perseverance on the physical therapist's and patient’s part to address all of the components affected by this very complex problem. There obviously must be a better way to address low back pain, especially before it transitions from an annoying bee sting or two to a fire-breathing dragon that feels impossible to defeat.
In the midst of a caseload of chronic pain patients, I was excited to meet a new patient with acute low back pain that was only a week or so old. While the severity of the low back pain was very high (the patient had just visited the emergency room due to pain and the inability to move), the potential for swift success was still quite possible. With the evaluation completed, a treatment plan was developed that incorporated manual therapy (hands-on) techniques to mobilize the spine (get the spine moving) and the soft tissue attached to the poorly moving spine segments, as well as flexibility exercises to maintain this newly achieved motion at home. Activity modification (avoiding pain-free activities), use of ice to control pain when present, sleep positioning, and office postures were also addressed with the patient. After several visits, the patient’s pain was nearly completely resolved, and the treatment plan progressed to instruction on body mechanics for basic movements such as bending and squatting, and stabilization and strengthening exercises for the spine and hips. Finally, the patient was instructed in how to squat and lift for functional lifting activities at home, and advice was given on work-out activities that would promote spine health along with a progression to more challenging home exercises that would help prevent any return of low back pain in the future.
What a difference the chronicity of a patient’s pain can make! While the average chronic low back pain patient may be seen in physical therapy for 14 visits or more, this acute low back pain patient was seen for just 7 visits, start to finish! The patient’s pain was fully resolved in 4 visits, with the final visits utilized to teach the patient the movement patterns and exercises needed to prevent his pain from becoming chronic or returning in the future. The patient’s low back disability score (Oswestry Low Back Pain Disability Questionnaire) went from 44% (severe disability) down to 0%! Needless to say, this makes for a happy patient, happy physical therapist, and even happier referring physician!
Down the road savings in healthcare costs from fast and effective treatment of acute chronic back pain is easy to see when a patient can avoid long term medication use, time off of work on disability, referrals to advanced specialists, and orders for radiological studies such as X-rays and MRI’s. The effectiveness and cost savings of medical care due to swift referral to physical therapy by primary physicians to quickly address low back pain is well supported in recent medical research. In a study by Fritz et al,1 published in Spine in 2012, indicated that only 7% of patients with acute low back pain were referred to physical therapy by their primary physician (but this varied by geographic location). However, in a sub-group of patients who were referred to physical therapy within 14 days of the start of their back pain, there was a significantly reduced risk of need for additional physician visits, advanced imaging, opioid medications, injections, and surgery.1 In another study published in Spine in 2012, Gellhorn et al,2 reported that early access (within 30 days) to physical therapy for acute low back pain resulted in reduced risk for additional physician visits, spine injections, and eventual surgery.
The takeaway from this case study is pretty clear. If you have acute low back pain, being referred to physical therapy may be the best first and last step in effectively addressing your pain without the need for additional interventions. The next time you are seen for low back pain, remind your physician of the benefits of physical therapy to address low back pain, and ask for a referral to a physical therapist with manual therapy training. If you can’t get in to see your physician, call your insurance company to see if you can refer yourself directly under your insurance plan. Time is of the essence to ensure the success of your care, and who wants to be in pain longer than you need to be?
1. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine, 2012:37(25):2114-21.
2. Gellhorn AC, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine, 2012:37(9):775-82.