Low back pain is one of the most common reasons employees go to the doctor or miss work. It also is a major health care cost driver. Some traditional methods for managing low back pain could fit the definition of low-value health care – costly tests and invasive therapies that may not help patients and frustrate clinicians and payers. As evidence mounts that more intensive therapies do not always mean better outcomes for back pain sufferers, health systems around the country are developing new, innovative programs for back pain that focus on noninvasive, nondrug therapies. New guidelines from the American College of Physicians (ACP) that came out last week also emphasize conservative, non-drug and non-surgical treatments such as mindfulness-based stress reduction, tai chi, and acupuncture.
The guidelines strongly discourage the use of opioids, encourage nondrug therapies, and provide specific guidance for acute, subacute, and chronic low back pain:
The ACP relied on randomized controlled trials and systematic reviews of studies evaluating noninvasive, nondrug, and drug therapy for low back pain in adults, along with feedback from a public comment period, to develop the guidelines.
Two years ago, some large employers in Seattle wanted to address low back pain in their employee population. The employers worked with Virginia Mason Hospital and Medical Center in Seattle to develop a spine care program that aimed to improve service and same-day access for employees and reduce unnecessary medical care. The spine clinic began reserving slots in the schedule for same-day appointments for patients with acute back pain. Physicians also created a new form for ordering MRIs that required patients to meet certain criteria. This process cut down on unnecessary imaging that can drive up costs and expose patients to potentially harmful radiation. The program also included increased access to physical therapists (PT), who were able to listen to a patient’s concerns, assess mobility, and do basic diagnostic testing. This allowed physicians to spend their time developing a care plan with the therapist and patient. The program has shown early successes in reducing costs, increasing patient satisfaction, and less time missed from work.
Cleveland Clinic is also targeting chronic low back pain by creating a pilot population health initiative aimed at helping patients recover and become active again. The initiative launched last year and emphasizes functional outcomes rather than procedure-based care, with a focus on combination of physical therapy and behavioral medicine. It targets patients at high risk for extended disability.
The program takes a multidisciplinary approach: A team of PTs and behavioral medicine specialists treats participants in the 12-week pilot program. The program has individual therapy sessions with a PT and group conditioning sessions. The individual sessions use manual therapy and corrective exercise, but also rely on pain neuroscience education, which helps patients understand more about their pain which may reduce their anxiety about it. Physicians support the program by reinforcing the messages from the rest of the care team.
Analysis: An editorial by a specialist at Massachusetts General Hospital appearing alongside the guidelines published in the Annals of Internal Medicine noted what a major change nondrug therapy is for primary care clinicians treating back pain. The editorial called for more studies with real world applications so that drug and non-drug approaches can be assessed as they are applied in routine practice. They are usually combined (medication plus PT) or used sequentially – starting the new intervention after the one before it fails. In particular, the recommendation for patients with acute or subacute low back pain to try nondrug therapies first may be challenging for primary care clinicians. The main challenge in widespread adoption of nondrug therapies will likely be lack of insurance coverage, patient access, and affordability, the editorial concluded.
(Sources: Amir Qaseem, Timothy J. Wilt, Robert M. McLean, Mary Ann Forciea, for the Clinical Guidelines Committee of the American College of Physicians, Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians, Annals of Internal Medicine, February 14, 2017; Steven J. Atlas, Management of low back pain: Getting from evidence-based recommendations to high-value care, Annals of Internal Medicine, February 14, 2017)
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