Early initiation of physical therapy (PT) for U.S. patients with acute lower back pain (LBP) was associated with less health care resource use in the first month and the first year after the initial onset of symptoms, according to a new study by Johns Hopkins Medicine. These health care resources included advanced imaging, specialty appointments, epidural steroid injections and emergency room (ER) visits. Patients who began PT early were half as likely to visit the ER within 30 days of symptom onset than those who did not receive early PT, which the study defined as starting within two weeks of symptom onset.
The study was published by BMC Health Services Research in July 2022.
Lower back pain affects a sizeable portion of the U.S. population, ranging from 1.4% to 20%, and it accounts for substantial health care expenditures.
"Our goal was to determine if early PT for patients with lower back pain had an impact on their overall health care resource utilization," says Richard Skolasky Jr., Sc.D., M.A., the study's senior author and the director of the Johns Hopkins Spine Outcomes Research Center. "We were especially curious about the 30 days after initial symptom onset, as this is when patients are most likely to seek care."
Using Truven MarketScan, a group of U.S.-based administrative health care insurance claims databases, the researchers selected nearly 980,000 U.S. claims cases. The de-identified patients in these claims had an average age of 47 and initially presented with acute LBP from 2010 through 2014. Approximately 11% of the patients received early PT.
From the cases reviewed, the team assessed the use of health care resources and the cost of the LBP-related services that were coded with a musculoskeletal system diagnosis. The team then compared these results at 30 days and at one year after presentation between patients who received early PT and those who did not.
Compared with those who did not receive early PT, the early PT group had a significantly lower incidence of using health care resources, such as ER visits, in the first month and the first year after presenting with acute LBP. The early PT group also spent less money on LBP-related services in the first 30 days after symptom onset.
"As the U.S. population ages, the prevalence of lower back pain is expected to increase, along with the associated costs of treating it," says Skolasky. "Furthermore, with advances in imaging and treatments, the cost of managing lower back pain has increased substantially. Our findings have important implications that may guide health care policy when examining downstream health care costs and resource utilization."
The research team believes that future research on the effects of early PT should incorporate measures of clinical outcomes to determine its impact on patient health.
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Materials provided by Johns Hopkins Medicine. Note: Content may be edited for style and length.
Low back pain is a common global problem. The point prevalence of low back pain in 2017 was estimated to be about 7.5% of the global population, or around 577 million people. Low back pain is the most common diagnosis seen by physical therapists. Most cases will resolve in less than two weeks with little to no treatment, but back pain that is sharp, shooting or radiating warrants a timely referral to prevent the symptoms from becoming debilitating.
- Do I need physical therapy for my back pain?
- Understanding chronic low back pain
- What are good exercises for low back pain?
- How can I maintain a healthy lower back?
Do I need physical therapy for my back pain?
If you are in generally good physical health with a regular fitness routine and do not have pain that radiates into your legs, your low back pain is likely to resolve without treatment. Physical therapy is often advised for individuals who are at risk of developing chronic low back pain. Often, this is the patient with severe, unremitting pain or symptoms that radiate into the legs that may also have numbness and tingling.
Once we have ruled out serious conditions that may require immediate medical intervention, a physical therapist will design a treatment program that:
- Improves structural impairments in your spine and pelvis.
- Relieves pain or modifies your current pain experience.
- Returns you to your normal activities as quickly as possible.
While it may seem better to stay in bed and wait for the pain to resolve, this has been shown to be counterproductive to the natural healing process. Instead, it is recommended to remain active, modifying or reducing your regular exercise routine as tolerated, with a gradual return to your normal activities.
Understanding chronic low back pain
Pain is usually thought of as a sign of injury, such as the pain of a cut or a fracture, but low back pain is different. Low back pain can be intense and persistent but it does not necessarily indicate the presence of a serious, ongoing injury. X-ray and MRI results are often not representative of the intensity of pain a person reports. Various studies have shown that people who experience more intense low back pain often have “better” MRI results than those who have less intense low back pain. The question is – why do people have different pain experiences regardless of the findings on their MRI studies?
To answer this question, researchers have investigated how and why we feel pain. They have observed that pain is an experience created by the brain when there is danger or the threat of danger to the tissues. During this process, the brain gathers information from the rest of the body, your memory and emotions, and decides if pain should be felt or not. Your nervous system perceives low back pain as a significant danger. This perception of danger will prompt you to stay in bed and rest, but this is typically the wrong approach. Your physician or physical therapist’s advice will probably be to stay gently active, which will get you back on your feet much sooner.
Understanding pain will also assist you in determining which activities are beneficial and which can be potentially harmful. In general, staying active will benefit you more than being sedentary. Most day-to-day activities such as walking, light exercise, and household chores are beneficial for your back.
Activities that place excessive loads on the low back, like lifting heavy objects with poor control, can sometimes worsen the pain. Sometimes you may find yourself avoiding certain activities because you are worried about feeling pain.
What are good exercises for low back pain?
One approach physical therapists use to help you overcome your fear of activity that causes pain is called graded activity. This is a gradual increase of performing the activities that hurt your back. Graded-activity exercises break down the painful activity into smaller, pain-free movements. This encourages your nervous and musculoskeletal systems to create a new, positive feeling about the activity.
For example, you might experience low back pain every time you lift your children from the floor. Using the concept of graded activity, you can start by doing unweighted squats. Then, you may lift a five-pound object from the floor. On the following visit you might lift a 10-pound object. You will continue this gradual progression until you have acquired the ability to lift your children from the floor.
Here are some of the concepts typically included in a graded-activity education session:
- Low back pain is a benign condition and nothing is seriously wrong with you.
- The exercises are intended to help you feel safe moving, not to necessarily increase strength.
- Complete pain relief is not needed to return to work/sports.
- The focus of these sessions is on the ability to be active, not pain-free.
- You and your therapist will set a gradually increasing goal to be reached at each session.
- You and your therapist will agree on a goal date for returning to work/sports.
How can I maintain a healthy lower back?
Once your physical therapy regimen is complete, and you have returned to your previous level of activity, it is important to maintain a healthy lifestyle. Low back pain might resolve quickly but has a tendency to return in the future if you are not mindful. Those who have experienced more than one episode of back pain know that being proactive goes a long way. Here are a few points to consider:
- Exercise routinely.
- Eat better.
- Maintain good posture when standing/sitting.
- Sleep seven to eight hours.
- Avoid lifting heavy objects – ask for help whenever possible.
- Spend time with your loved ones.
At Hospital for Special Surgery, our physical therapists use graded activity and other research-based techniques to help people get back to their work and leisure activities.
Updated: 1/12/2022
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