Imagine that you just recently bent over to get the laundry out of the drier and “threw your back out.” You now have low back pain, occasional pain radiating down your right leg, and are having significant difficulty walking, sitting, and sleeping comfortably. Several weeks pass and you are thinking, “This will probably just go away on its own, I’ll just put some heat on it and wait it out.” The reality is that you have not experienced any relief and in fact, that pain that was just occasionally radiating into your right leg is now constant. You visit the infamous “Dr. Google” and self-diagnose yourself with a herniated disc, arthritis, and spinal stenosis because hey, “With how bad this pain is it must be all of the above.” You finally visit your primary care physician who may or may not refer you to a spine specialist or orthopedic physician. Regardless of this, you are given a script for “Low back pain and lumbar radiculopathy” and are told that you must try physical therapy first prior to undergoing any diagnostic imaging, trialing cortisone injections, or even consult about surgery. But why?
Conservative Treatment For Low Back Pain
Often times conservative treatment is recommended first over more serious, aggressive interventions as it is the preferred approach, as studies have shown that conservative treatment can reduce both patient and healthcare spending and frequently result in similar functional improvements reported by the patient.
McKenzie® Method, Maitland, and Low Back Pain
There are various treatment theories and intervention strategies that physical therapists use to treat low back pain, and many are effective. Two of the most common treatment philosophies include the McKenzie® method and Maitland approach. Each technique emphasizes localized treatment to the spine to reduce pain and stiffness both locally at the spine as well as into the peripheries and adjacent joint structures. A study in 2018 conducted by Lam et al. indicated that treatment of chronic low back pain with the McKenzie method is superior to other rehabilitation interventions.1 A similar study regarding treatment using Maitland techniques, conducted in 2015 by Sharma et al. indicates that the use of Maitland mobilizations in managing low back pain are more effective than conventional treatment, including traction and stretching.2 Both studies demonstrated improvement in functional outcome in both the MDT (McKenzie) and Maitland groups more so than other conventional treatment groups.
McKenzie Method For Low Back Pain
The McKenzie method revolves around the theory of “directional-preference,” or put simply, establishing a direction for a segment of the body to move that improves/reduces symptoms. This centers around the idea of patient-centered care and promotes independence with treatment techniques providing patients with an ability to perform exercises within their “directional-preference” to independently reduce or resolve their pain. This allows patients to self-manage their symptoms at home, requiring less frequent PT visits, and thus further reducing patient spending.
Functional Outcomes and Low Back Pain
Physical therapists, in addition to other healthcare professionals, measure objective improvements reported by their patients using questionnaires classified as functional outcomes. Functional outcomes essentially ask questions centered around the functional aspects of daily living, answered by patients, to establish the level of difficulty or “impairment” that the patient experiences with each activity. For low back pain specifically, the Oswestry Disability Index (ODI) is utilized to measure such levels of impairment. Studies including Bydon, et al in 2014 have examined the relationship between surgical groups versus conservative therapy and their effects on the ODI, with results supporting the referral to physical therapy first prior to undergoing surgery: there is no significant difference between improvements on the ODI in the surgical group as compared to the non-operative/physical therapy group.3 A similar study conducted by Wang, et al in 2015 analyzed the results of 6 different randomized controlled trials examining the difference in ODI scores when comparing surgical (lumbar fusion) versus non-operative (physical therapy) treatment interventions, which yielded similar results: no significant difference in ODI scores between either group, again indicating that surgical and non-operative treatment interventions yield similar patient-perceived improvements.4 The take-home message here: studies are showing that patients experience similar improvements from physical therapy treatment as they do after receiving surgery.
Cost Savings, Direct Access, and Low Back Pain
Aside from similar improvements in outcomes, the treatment of low back pain conservatively not only saves the patient money, but also helps to reduce overall healthcare costs. A study conducted in 2015 by Childs et al indicates that those patients who received early guideline adherent physical therapy associated with significantly utilization for all outcomes and an overall 60% reduction in total low back pain related costs.5 A similar study conducted by Denninger et al in 2018 indicates that patients who entered care including a physical therapy-led spine management program via direct access showed significantly lower total costs (approximately $1,500 mean difference) than those who chose traditional medical referral. The study goes on to indicate that patients who chose PT first incurred less of a cost expense, but also recovered more quickly.6 Direct access, mentioned in the previously referenced article, allows for patients to participate in physical therapy services without requiring a referral from their primary care physician or orthopedic specialist; however, not all states allow for direct access (you can find out if your state allows for direct access using the link at the bottom of the article). In general, only 20 states allow for unrestricted direct access, while 27 allow for direct access with a referral within a specified time, and 3 states allow for limited direct access. With this direct access, and the lower costs to the patients, we can reduce the amount of money spent on diagnostic imaging and increase the potential to lessen the amount of elective surgeries performed.
On occasion a patient may benefit from more aggressive treatment interventions including injections and surgeries. The truth is, not every patient will benefit from physical therapy, just like not every patient benefit from surgery. It is the goal of every health care professional to work together as a cohesive healthcare system of clinical and medical professionals to help our patients achieve their goals and return to a pain-free quality of life using our expertise and clinical judgment. Before asking why you are being referred to physical therapy prior to even undergoing any imaging, trying injections for quick pain-relief, or going through a taxing recovery after surgery, know that therapy IS an option. Remember that as the patient, you have every right to choose your best path to recovery based on the resources and education provided to you, and that a referral to physical therapy, alone, may just be enough.
Link for direct access: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf
Written By: Connor Drislane, PT, DPT, Certified Vestibular Therapist, Aquacare Lewes 24
1) Lam OT, Strenger DM, Chan-Fee M, et al (2018). Effectiveness of the mckenzie method of mechanical diagnosis and therapy for treating low back pain: literature review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 48(6), 476-490. https://www.ncbi.nlm.nih.gov/pubmed/29602304
2) Sharma A, Alahmari K, Ahmed I (2015). Efficacy of manual therapy versus conventional physical therapy in chronic low back pain due to lumbar spondylosis. A pilot study. Med Sci (Basel). 3(3), 55-63. https://www.ncbi.nlm.nih.gov/pubmed/29083391
3) Bydon M, De la Garza-Ramos R, Macki M, et al (2014). Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Spinal Disord Tech. 27(5), 297-304. https://www.ncbi.nlm.nih.gov/pubmed/24346052
4) Wang X, Wanyan P, Tian JH, Hu L (2015). Meta-analysis of randomized trials comparing fusion surgery to non-surgical treatment for discogenic chronic low back pain. J Back Musculoskelet Rehabili. 28(4), 621-627. https://www.ncbi.nlm.nih.gov/pubmed/25467996
5) Childs JD, Fritz JM, Wu SS, et al (2015). Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Serv Res. 9(15), 150. https://www.ncbi.nlm.nih.gov/pubmed/25880898
6) Denninger TR, Cook CE, Chapman CG, et al (2018). The influence of patient choice of first provider on costs and outcomes: analysis from a physical therapy patient registry. Jo