Physiotherapy/Advanced Imaging as First Management Strategy for Acute Low Back

Roughly eight years ago, practice guidelines began recommending against advanced imaging (CT or MRI) as an initial response to uncomplicated low back pain, and they continued recommending referrals to physiotherapy. While the rate of early advanced imaging for uncomplicated low back pain has decreased since its high in 2007, the percentage of uncomplicated LBP patients referred first to physiotherapy is roughly equal to the percentage of those patients referred first to advanced imaging. Last March, Health Services Research issued an early release of research contrasting the two approaches.

 

Dr. Julie Fritz and colleagues examined the insurance and electronic health records of 2,893 patients with new, uncomplicated low back pain who presented to primary care practitioners. They followed for one year the insurance expenses of patients who received a physiotherapy referral within six weeks, and compared those expenses to patients who received an advanced imaging referral within six weeks. Patients who received both services were categorised by which service they received first. After one year, the patients referred to physiotherapy first averaged $8,105 less in costs compared to the advanced imaging group. The advanced imaging group showed several signs of having a more serious condition than the physiotherapy group, so the researchers used propensity matching to create subgroups that were matched for signals such as comorbidities, medication use, and presence of radiographs at first visit. Among the propensity matched groups, physiotherapy referrals still correlate with a $6,273 lower average cost at one year. The researchers note that they did not have access to certain data such as pain scales and symptom duration that would have further matched the two groups.

 

The increased expenses incurred for the advanced imaging group exceed the cost difference between physiotherapy and advanced imaging. Others have suggested that advanced imaging may “label” uncomplicated back pain in ways that influence patients to worry more and incur more direct and indirect costs. Dr. Julie Fritz and colleagues reference consumer research demonstrating that some LBP patients go to their doctors with an expectation of receiving something perceived as beneficial, and that breaking this expectation can create additional problems. For these cases, Fritz and colleagues offer that a referral to physiotherapy can be more protective for patients and the healthcare system than a referral for advanced imaging that the doctor would not otherwise have elected.   

 

The researchers offer that their evidence adds to a collection of data showing that physiotherapy is often the preferred early referral in cases of uncomplicated low back pain. A study published in Spine in 2012 shows that patients who begin physiotherapy within 14 days of their primary care consult cost $3,058 less than those who begin physiotherapy later and are 55% less likely to need surgery. Julie Hides, PhD, et al. demonstrate that patients managed passively have a 180% greater recurrence rate than patients receiving physiotherapy, and Vinicius Oliveira and colleague show that the results of self-care alone are insignificant. The physiotherapy interventions in these studies are active, hands-on treatments involving corrective exercises and often including ergonomic advice. Passive interventions such as therapeutic ultrasound have not been shown to be beneficial unless accompanied by an active approach to treatment.

 

The Most Important Risk Factor in Preventing Low Back Pain

 

Abstract: A recent meta-analysis attempting to find predictors of low back pain (LBP) largely failed to identify any consistent, significant risk factor for increased incidence - with one important exception. Previous LBP continues to be the most important risk factor for future LBP. This result supports the long-emerging concept that most LBP announces deconditioning, not an injury, and almost all LBP episodes merit treatments to interrupt the deconditioning process.

 

At any given point in time, back pain affects roughly 10% of the world’s population. While back pain ranks as one of the ten leading causes of disease burden globally, it is the only one of the ten where there has been no global progress in prevention. A meta-analysis published recently in Spine Journal combines forty-one studies in an attempt to identify risk factors associated with low back pain (LBP) incidence. Understanding risk factors could serve to improve prevention strategies. 

 

With one very important exception, the meta-analysis finds no consistent risk factor of first-time LBP. Occupation, older age, patient beliefs regarding low back pain, decision authority at work, supervisory support at work, and other variables are not significant in predicting a higher incidence of LBP. Poor general health emerged as an inconsistent risk factor. However, prior LBP consistently emerges as a significant predictor of future LBP. Prior LBP is the most important risk factor for incident of low back pain. 

 

A singular recent study out of Sydney attempts to identify modifiable “triggers” of acute LBP episodes to inform future attempts to improve prevention. Unfortunately, there is no comparison group save each subject’s own 50-hour history before onset of pain. More importantly, results involving the concept of LBP triggers must be interpreted with caution. The idea of an LBP trigger alludes to an older concept that most cases of LBP should be thought of as an injury (or in this case, an ‘accident’). However, many of the triggers discussed in the Sydney study and triggers that a patient may report to a clinician are often activities or circumstances that the patient experiences multiple times per year over several years, without incident (e.g. distraction, posture, heavy work, fatigue). There is a strong probability that very concept of triggers and injury-related risk factors are a bit of a misdirect in LBP prevention efforts.

Our current knowledge of LBP has transitioned to the concept that LBP is no more an injury than a heart attack is an injury.  Rather, acute, non-specific, LBP announces a disease process more akin to a deconditioning syndrome. Furthermore, we now understand that the majority of LBP healthcare costs stem from re-use of the system. This concept aligns with the meta-analysis findings that most predictors of first-time LBP are insignificant, general health may be important, and the most important predictor is previous LBP. To protect patients and to control healthcare costs, future and potentially worse LBP events must be avoided.  

 

LBP serious enough to prompt a visit to a primary care practitioner announces an opportunity to interrupt the deconditioning process. Physiotherapy is known to do this cost-effectively. A study published in Spine in 2012 shows that patients who begin physiotherapy within 14 days of their primary care consult cost $3,058 less than those who begin physiotherapy later and are 55% less likely to need surgery. Julie Hides, PhD, et al. demonstrate that patients managed passively have a 180% greater recurrence rate than patients receiving physiotherapy, and Vinicius Oliveira and colleague show that the results of self-care alone are insignificant.