Conservative Care: Treating Lower Back Pain

​Primary care physician visits for lower back pain (LBP) have increased over recent years, and LBP continues to be one of the top five reasons to see your doctor. Many physician groups have provided clinical practice guidelines that offer direction on how to make smarter choices with respect to LBP and advanced imaging procedures such CT scans and MRIs. eviCore incorporates these evidence-based guidelines into its own determinations in order to ensure its client's patients receive the best care.

Well-established research has shown that patients who received advanced imaging before trying more conservative care, such as physical therapy, incurred higher costs by an average of $4800. Moreover, the findings in imaging—such as disc degeneration, arthritis, bulging discs, etc.—may not identify the actual cause of your pain.

As a matter of fact, if you are age 30 or older your imaging may show all of the above, but you might not have any back pain limiting your function. Yet now that you and your doctor know that those ugly-sounding conditions are there, pressure is exerted on your physician (and yourself) to do something about those imaging findings … and that leads to more procedures and higher costs.

The emerging research and data show very strongly that conservative choices, especially physical therapy, should be the first choice. A 2013 JAMA study examining 440 million visits for LBP over a 10-year period revealed:

1.  Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9 percent in 1999–2000 to 24.5 percent in 2009–2010. In contrast, narcotic use increased from 19.3 percent to 29.1 percent .

2.  Although physical therapy referrals remained unchanged at approximately 20 percent, physician referrals to specialists increased from 6.8 percent to 14.0 percent.

3.  The number of radiographs remained stable at approximately 17 percent, whereas the number of computed tomograms or magnetic resonance images increased from 7.2 percent to 11.3 percent during the study period.

Reductions in inappropriate opioid use and higher-cost procedures should be the goals of any healthcare system. We have the research findings that clearly make the case for better choices. Unfortunately, many healthcare providers are not practicing that way. According to another study, of the 170 million visits to physicians for LBP examined from 1997–2010, only 10 percent of those cases were referred to physical therapy; opioid prescription rose by 30 percent during the same time period. Yet the data shows that early access to the "right" evidence-based treatment reduces costs. For example, people who started physical therapy within 14 days of onset experienced lower costs, and potentially reduced future costs by alleviating chronic conditions and avoiding surgery.

In addition, physical therapy versus surgery for disc degeneration or spinal stenosis has been shown to achieve basically the same outcomes in pain and function at 2-year and 5-year follow-up studies. Comparing both treatment paths, any existing pain and function differences narrowed over time, which was reflected in the statistically insignificant differences found on follow-up studies. So are the risks and costs associated with surgeries worth the immediate but temporary changes, with no long-term advantage over the lower-cost options? As healthcare costs continue their seemingly inevitable rise, clearly it is past due time to reexamine the choices we are making— both as providers and consumers—in the treatment of LBP.