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Raymond Gardinier: Low Back Pain is a global problem, accountable for many opioid prescriptions

Low Back Pain (LBP) is one of the most common injuries endured across the globe and is a major health problem worldwide, affecting 60-80% of people of all ages and income levels at some time in their lives.

There has been a 54% increase in the number of years lived with disability in those suffering from low back pain between 1990 and 2015. It is now the leading cause of disability and has been shown to lead to high healthcare costs resulting in substantial economic consequences due to low efficacy treatments and loss of productivity. Approximately $80 Billion is spent on spine-related conditions each year with an additional $10-20 Billion lost in economic productivity.

In addition to the dramatic rise in the number of years individuals suffering from low back pain are living with, there are almost 58 opioid prescriptions written for every 100 Americans according to the Centers for Disease Control and Prevention (CDC). However, considering there has been no reported overall change in the number of pain Americans are living with over the last few years, the CDC released opioid prescription guidelines in 2016 and recommended non-opioid approaches to pain management including physical therapy in an effort to cut down on the growing problem. Opioids are created and prescribed to relieve pain, not to resolve the underlying issue. They work by interrupting pain signals to the brain thereby reducing sensation. In other words, they mask the pain and not to mention carry significant risks and side effects including depression, overdose, addiction, and withdrawal symptoms when stopping use.

Raymond Gardinier

Furthermore, the push to avoid the use of opioids in the management of low back pain is not the only topic of debate for this injury. A number of other tests and treatments have received criticism over the years on their cost-effectiveness. Advanced imaging (MRI) is often used in patients with back pain to help determine the etiology. Common findings in those with back pain include disk degeneration, facet hypertrophy, and disk protrusion, however, similar structural changes have also been shown to be present in a large proportion of individuals who are completely asymptomatic.

Many studies have demonstrated a high prevalence of degenerative spine changes in asymptomatic individuals as shown on advanced images. It’s also been shown that as we age there is an increasing prevalence of structural changes with >50% of individuals aged 30-39 and almost 90% of individuals >60 years old displaying disk pathology, yet have no symptoms. This leads to the question – if those with and without lower back pain demonstrate similar changes when looked at under an MRI, what is the purpose of the initial imaging? An MRI is highly sensitive in detecting structural changes within the spine, however, it’s findings are not necessarily associated with the degree or the presence of a patient’s back pain.

Not only does an MRI seem irrelevant in the initial presence of low back pain considering it’s fairly low correlation to a patient’s pain, but it’s also been shown to increase patient spending and healthcare costs. A recent article demonstrated those who suffer from low back pain and consulted a physical therapist first averaged $904 spent after 1 year, much lower than the $2,283 of those who seek initial care from certain physicians. This may be from the fact that patients who seek out musculoskeletal care first from a physical therapist have fewer tests performed, less imaging, and fewer injections/surgeries. Now that we have an understanding of where the increased costs of LBP could potentially arise from, you may be wondering how do the outcomes compare for those who receive PT vs. other forms of treatment?

Lumbar disc herniation is a common pathology of the lower back and one of the main causes of sciatica, usually as a result of pressure on or irritation of the sciatic nerve root. Lumbar discectomy is the most popular surgical procedure performed in patients with sciatica from a herniated disc, however, there’s been some promising literature supporting other conservative forms of treatment with similar outcomes. A 2016 article published in the British Medical Journal found patients who received surgical treatment for lumbar disc herniation found faster relief of pain symptoms, however, did not show a benefit over conservative treatment in mid-term and long-term follow up.

Another pathology commonly leading to low back pain and disability, spinal stenosis, is often the result of degenerative and arthritic changes of the spine. A 2015 study looked at the outcomes of surgery vs non-surgical treatment (PT) in patients diagnosed with lumbar spinal stenosis. Those in the surgery group underwent surgical decompression and were also shown to have similar outcomes (pain and physical function) as the physical therapy group two years later.

What does this mean?

When comparing surgery vs. physical therapy for the treatment of low back pain we have seen similar outcomes in the long run with significantly fewer complications and fewer costs. There is strong evidence for the effectiveness of physical therapy treatments including manipulation, education, activity modification, and exercise therapy for chronic low back pain.

Rehabilitative exercises typically consist of individually designed programs with a combination of stretching, strengthening, and aerobic exercise. A well-designed physical therapy program should be at the forefront of your low back pain plan of care especially if your pain has persisted for years. If physical therapy fails, the decision of if and when to have surgery, injections, or other treatments should be driven by your preferences, not the healthcare providers’ interests.

For more information on how physical therapy can help your back pain, give us a call on 859-916-1334 or send an email to ray@ranierphysicaltherapy.com

Dr. Raymond Gardinier, PT, CSCS has been a patient, student, and physical therapist for over 8 years. He earned his Doctorate in Physical Therapy from Long Island University after obtaining his undergraduate degree in Exercise Science from Northern Kentucky University. He is also a Certified Strength and Conditioning Specialist, CrossFit Level 1 Trainer, and the practice owner of RANIER Physical Therapy. Gardinier is a member of the American Physical Therapy Association, APTA Private Practice Section, and National Strength & Conditioning Association. He currently specializes in general and sports medicine injuries and sees patients at RANIER Physical Therapy located in Ft. Wright.

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