Lower Back Pain (LBP) is the leading global cause of activity limitation and missing work.(6) It is one of the top 15 priority conditions in the United States, and many researchers seek urgently to learn how to reduce the challenge it places on individuals, practitioners, and the healthcare system.(5).
Research showing that LBP has high levels of recurrent and costly episodes adds to this urgency. A study by Wasiak et al. investigated the costs of recurrent episodes, considering over 1800 individuals with previous and recurrent episodes of nonspecific LBP. They found that the recurrent episodes of LBP led to a 17.2% recurrence in work disability, 33.9% recurrence of seeking care, and 13.1% recurrence of both work disability and care recurrence. The study concluded that individuals with recurrent episodes of LBP had significantly higher total medical and indemnity costs and longer duration of work disability than individuals without recurrent episodes of LBP, pointing to the disproportionate costs of recurrent episodes of LBP to work productivity and healthcare utilization.(10) Wasiak’s study emphasizes the cost to individuals and to the healthcare system caused by recurrent LBP. To reduce healthcare utilization, treatments must prioritize both addressing present LBP episodes and preventing their recurrence.
Clinical practice guidelines (CPGs) present outlines for LBP treatment that emphasize these two goals. These CPGs have already proven beneficial in non-LBP treatment. Indeed, there is plenty of evidence showing that clinical treatments in general are more effective when administered in adherence with CPGs.(4) Many CPGs specifically for the treatment of LBP have been developed, and they emphasize two aspects of treatment that are crucial for addressing immediate LBP and preventing recurrent episodes: active recovery and patient education. All CPGs for treating LBP without surgery emphasize active rehabilitation approaches, which have been shown to improve patient outcomes.(8),(3) This active rehabilitation helps patients gain control over and heal their LBP. CPGs also recommend clinicians educate patients on their condition, empower them to contribute to long and short term management of LBP through lifestyle changes, and counsel them on fear-coping strategies.(2),(3) These ways of educating patients play a key role in preventing costly recurrent LBP episodes because they give patients the skills and knowledge they need to protect their recovery, avoid pain triggers, and deal with potentially damaging psychological consequences of LBP.
These factors of CPG-adherent treatment of LBP have been shown to reduce LBP-related healthcare utilization costs by 60% when the treatment begins early after a patient reports their symptoms.(1) To determine whether adherence to CPG at any stage after experiencing symptoms affects healthcare utilization in the treatment of LBP, Hanney et al. in 2016 performed a literature review of 256 peer-reviewed papers on the impact of CPG-adherent physical therapy practices on subsequent healthcare costs and utilization. The review found that in most cases, patients with LBP who were treated with a particular guideline program had decreased healthcare utilization, reported fewer average visits to a physical therapist, physician, or emergency department, had less use of advanced imaging, fewer injections, fewer surgical procedures for LBP, and had less usage of prescription medications for LBP.(5) Unsurprisingly, the CPG-adherent group also saved more on healthcare costs, paying less on average for physical therapy, inpatient costs, and medications.(5) This review adds strong support the use of CPG’s not only to improve patient outcomes but also to reduce the cost of LBP on the healthcare system.
These effective CPGs exist alongside high healthcare utilization for LBP because clinician adherence to the guidelines is low. A 2017 study of 410 physical therapists in the United States found that adherence to the guidelines varied widely by the specialization level of the clinician, ranging from 29.5% to 72.2% adherence.(7) Even at the high end of this range, many clinicians provide treatments that do not incorporate all of the elements proven to help patients heal and reduce LBP-related costs. To understand how to respond to low clinician adherence, Slade et al., studied the barriers to primary care physicians’ adherence to CPGs for managing LBP. They found that adherence to the guidelines could be improved by addressing clinicians’ misconceptions about CPGs. These misconceptions included thinking that the CPGs are based on poor evidence, lack organizational support, and are not preferred by patients. They also found clinicians believed that giving patients imaging referrals (which CPGs identify as useful primarily for planning surgery as opposed to planning the generally-recommended active recovery(2)) would help them manage confrontation with patients by meeting what they believed were patient expectations for a specific, unambiguous explanation of their LBP.(9) The physicians in the study believed this even though imaging has not been shown to provide certainty in explaining LBP.(2) What Slad et al. uncovered are physicians’ poor understanding of CPGs and their desires to meet patient expectations using methods not backed by research on efficacious treatments. This highlights the importance of reducing LBP-related healthcare utilization costs by educating clinicians and patients alike on CPGs, the evidence supporting them, and the organizations backing them.
To support better patient outcomes and decreased healthcare utilization that come with CPG-adherent treatment of back pain, Esurgi has created the Biostabilizer, a Pressure Biofeedback Unit (PBU), which gives real-time feedback on a digital interface to users performing rehabilitation tests. This device has a fast, one-button set up, and it enables physical therapists to help their patients relearn how to use core muscles to stabilize the spine. Based on the easy-to-understand auditory and visual feedback, users know whether they are performing the exercises correctly. This device will help clinicians support back pain treatments based on keeping patients safely active, as recommended by CPGs. It will also help clinicians adhere to CPGs by educating patients on how to correctly perform exercises and stay active to manage their condition on their own after treatment, reducing the likelihood of recurrent episodes. How could a PBU enhance your treatment of LBP?
1) Childs, J., Fritz, J., Wu, S., Flynn, T., Wainner, R., Robertson, E., Kim, F., George, S. (2015, April 9). Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research 15, article number 150. https://doi.org/10.1186/s12913-015-0830-3.
2) Delitto, A. et al. (2012, April 1). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 42(4), A1-A57. https://www.jospt.org/doi/10.2519/jospt.2012.42.4.A1.
3) Fritz, J., Cleland, J., Brennan, G. (2007, October) Does Adherence to the Guideline Recommendation for Active Treatments Improve the Quality of Care for Patients with ACute Low Back Pain Delivered by Physical Therapists? Medical Care 45(10), 973-980. doi: 10.1097/MLR.0b013e318070c6cd.
4) Grimshaw, J., Eccles, M., Russell, I. (1995, June 5). Developing clinically valid practice guidelines. Journal of Evaluation in Clinical Practice 1(1), 37-48. https://doi.org/10.1111/j.1365-2753.1995.tb00006.x.
5) Hanney, W., Masaracchio, M., Liu, X., & Kolber, M. (2016, June 10). The Influence of Physical Therapy Guideline Adherence on Healthcare Utilization and Costs among Patients with Low Back Pain: A Systematic Review of the Literature. PLOS ONE 11(6): e0156799. https://doi.org/10.1371/journal.pone.0156799.
6) Hoy, D et al. (2014, March 24) The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases. 73(6), 968-974. http://dx.doi.org/10.1136/annrheumdis-2013-204428.
7) Ladeira, C., Cheng, S., da Silva, R. (2017, April 30) Clinical Specialization and Adherence to Evidence-Based Practice Guidelines for Low Back Pain Management: A Survey of US Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy 47(5), 347-358. https://www.jospt.org/doi/10.2519/jospt.2017.6561.
8) Luna, E., Hanney, W., Rothschild, C., Kolber, M., Liu, X., Masaracchio., M. (2017, March 8). The Influence of an Active Treatment Approach in Patients with Low Back Pain: A Systematic Review. Sage Journals 13(2), 190-203. https://doi.org/10.1177%2F1559827617697273.
9) Slade, S., Kent, P., Patel, S., Bucknall, T., Butchbinder, R. (2016, September). Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain. The Clinical Journal of Pain 32(9), 800-816. https://doi.org/10.1097/AJP.0000000000000324.
10) Wasiak, R., Kim, J., Pransky, G., MoccH. (2006, January 15). Work Disability and Costs Caused by Recurrence of Low Back Pain: Longer More Costly Than in First Episodes. Spine 31(2), 219-225. doi: 10.1097/01.brs.0000194774.85971.df.