While all health professionals should agree that our clinical practices should follow the most current evidence, many consumers of health care would be surprised to learn about the pervasive gap between treatment and prevention and the most current research. Patients assume that their doctors or other health care professionals deliver care with knowledge of the most up to date information. Despite numerous clinical practice guidelines and evidence available, this is still very evident in the treatment of low back pain.
The American College of Physicians and the American Pain Society released a Joint Clinical Practice Guideline on Low Back Pain in 2007 in the Annals of Internal Medicine. Among the key recommendations were the limited use of diagnostic imaging with nonspecific low back pain, the importance of patient education, and use of first line medications like acetaminophen or NSAIDS versus opioids. The guideline also stressed that a thorough history and physical examination should always be performed on low back pain patients and that patients should receive treatments matched to this examination based on the findings. Even though these guidelines were issued 13 years ago, we continue to see treatment plans and preventative advice given to patients that have no validation in the literature.
Despite these evidence-based recommendations, we continue to see extensive use of diagnostic imaging when not supported for low back pain along with the continued overutilization of opioid medications. A biomedical approach frequently prevails over a biopsychosocial approach, where the focus is on tissue damage as an explanation for a patient’s pain versus educating our patients on modern pain science. And unfortunately there continues to be “cookie cutter” treatment design for patients with low back pain, where the same treatments are repetitively prescribed to every patients due to the lack of a quality history and examination.
But why does this happen? Why do we continue to see utilization of treatments that are ineffective and sometimes even unsafe? A March 2018 article in The Lancet summarized the evidence for prevention and treatment of low back injuries, identifying the gaps between evidence and clinical practice and offers examples of solutions that may provide alternatives to current care.
With regards to prevention, exercise with the combination of education is demonstrated to be most appropriate for low back pain. Despite this, there are numerous interventions with a very poor quality of evidence such as shoe inserts, education alone without exercise, and use of back belts that continue to be prevalent in practice. Poor postural alignment has long been an explanation for non-specific low back pain, but recent evidence shows that there is little correlation in patients with or without non-specific low back pain based on their specific postural alignment. We should be recommending that our patients should be utilizing a variety of postures and to move and change positions frequently, not focus on one correct posture, because this does simply not exist. Our bodies love a variety of positions, so we should be encouraging our patients to vary positions throughout the day between sitting, standing, walking, stretching and other positions as needed.
In regards to treatment of low back pain, self-management, physical therapy and exercise, and psychological therapy have been most highly supported by current evidence as most appropriate. Despite current guidelines deemphasizing the need for surgical and pharmacological interventions for low back pain, these options continue to be used with a high amount of prevalence. We continue to see patients receiving significant quantities of diagnostic imaging on their low backs, which feeds in to the perceptions that positive findings indicate that their backs are “damaged” or “broken”. These types of messages can be extremely frightening to a patient and significantly negatively impact their progress. Evidence has shown that patients with high levels of low back pain can have no signs of damage with imaging, and conversely there a number of people in the general population with significant findings on diagnostic imaging that have no symptoms at all. This same type of fear inducing message can be conveyed to patients when we tell them their back is “out of place”, “went out” or they “slipped a disc”, when no evidence supports these explanations as a cause of low back pain. Instead we should be educating our patients that pain does not necessarily mean damage, and that exercise and graded return to normal activity is safe and effective for nonspecific low back pain.
So why do we continue to over-utilize less effective interventions, give faulty preventative advice and under-utilize the most safe and effective interventions? The authors of The Lancet article identified some barriers including the limited amount of time providers get to spend with their patients, clinicians’ poor knowledge of clinical guidelines, fear of litigation and clinicians’ desire to maintain a harmonious relationship with their patients. The article did identify emerging solutions that align prevention and practice with the most current evidence; including a redesign of clinical pathways, integrating health and occupational demands to reduce work disability, changes in compensation and disability claims policies and public health and prevention strategies.
Physical Therapists see the prevalence of poorly chosen clinical pathways and utilization of interventions lacking supporting evidence frequently in their patient population. While Direct Access to Physical Therapy has helped to some extent, there is still a long way to go to change clinical pathways to get the right treatment to the right patient at the right time. In Workers’ Compensation, Physical Therapy continues to be viewed as a commodity and a cost driver rather than a cost saver, where the evidence proves to be exactly the opposite. It is up to the profession to demonstrate its’ value, and up to individual Physical Therapists to consume and follow the current evidence in order to treat patients appropriately.
Physical Therapy organizations like Results Physiotherapy provide the type of evidence-based low back pain care that make the profession proud and contribute to more effective clinical pathways. All of our Physical Therapists commit to a three year orthopedic training program, which ensures that our patients receive the highest level of evidence-based care. In addition, all of our patients see the same Physical Therapist at each visit, which optimizes therapeutic alliance, continual assessment throughout treatment and progression of care. Every patient receives an individualized treatment consisting of manual therapy, exercise and education, ensuring evidence based care.
Results’ clients see the value of our clinical excellence and refer patients to Results without hesitation. Eryn Crawford, President of CompPoint Managed Care/Brentwood Services Administrators, had this to say about her experience using Results, “Brentwood Services Administrators, Inc. uses Results Physiotherapy as a primary provider because we are confident in their clinical model of manual-based physical therapy. They use the most current, evidence-based care, and their therapists work with each patient to design a treatment plan that meets their individual needs and expedites recovery. Our patients deserve the best, and we believe Results delivers.”
Mitch Pousson, a case manager with Wright Rehabilitation Service went on to say “Results’ therapists exceed expectations in many aspects. One critical quality they possess, is the ability to precisely identify where the patient is, meet them at that point, and collaborate with the patient to restore wellness. The ability to address the acute needs, often associated with work injuries, and implement a smooth return to work, once deemed medically appropriate. At Results Everyone is treated with the upmost respect and always welcomed with a smile and personal touch.”
