Low back pain

SELF-REFERRAL FOR BACK PAIN IS CHEAPER FOR OUR PATIENTS

Patients who receive care from self-referring physicians for the treatment of low back pain (LBP) are more likely to be referred for some form of physical therapy, but that's just part of the story. According to newly published research, LBP patients who are self-referred receive fewer physical therapy visits and more ineffective passive modalities than patients who aren't self-referred—and all at a higher overall cost. The state of Kansas accepts self-referral for physical therapy! 

In the study, researchers analyzed 158,151 LBP episodes in private health insurance claims records for nonelderly individuals enrolled in plans offered by Blue Cross Blue Shield of Texas. They found that physicians who "self-referred"—that is, referred their patients to a business with which they have a financial relationship—referred 26% of their patients to physical therapy. That rate was 16 percentage points higher than among non-self-referrals. Overall physical therapy was referred at a rate of 14%. 

But the higher rate of referrals doesn't tell the whole story, according to the study's authors, who analyzed what happened next—and how much it wound up costing. Results of the study were e-published ahead of print in the Forum for Health Economics and Policy (abstract only available for free). 

What they found was that the self-referred patients received, on average, 2 fewer physical therapy visits and 10 fewer 15-minute physical therapy service units compared with treatments by providers who did not self-refer. And when self-referred patients did receive physical therapy, they were treated differently from their non-self-referred counterparts, with an increased use of passive modalities such as hot and cold packs, mechanical traction, ultrasound, and electrical stimulation—approaches authors describe as "ineffective" in treatment of LBP.

Looking more closely at Healthcare Common Procedure Coding System (HCPCS) records, authors found that about 46% of physical therapy services rendered during non-self-referred episodes included individualized exercises to develop strength, endurance, range of motion, and flexibility, compared with a 31.5% rate among the self-referred episodes. Significant differences were also found in the use of dynamic activities designed to improve function, which occurred at a 6.7% rate for non-self-referred episodes but in only 4.2% of the self-referred episodes. Conversely, electrical stimulation accounted for almost 9% of the physical therapy services in self-referring episodes. Among the non-self-referred episodes, use of that passive modality was 1.4%.

Authors write that the use of exercise and dynamic activities "implies that [LBP] patients treated by non self-referring providers received skilled one-on-one care," and that "patients seen by self-referring providers received higher proportions of passive treatments." According to the authors, these passive treatments "can be easily performed by non physical therapists (medical assistants or technologists) in physicians' offices," and billed as physical therapy services under the "incident to" rule.

And what about overall cost? It turns out that fewer physical therapy sessions and a greater use of passive modalities doesn't wind up saving money—in fact, the LBP episodes addressed through self-referral averaged $889 in insurer-allowed costs, compared with $602 for non-self-referred episodes—a 49% difference. As for spending on individual physical therapy services, self-referral episodes averaged costs that were double non-self-referrals—an average of $144 for the self-referring provider, compared with $73 for the non-self-referring provider.

Results of the study not only inform physical therapist practice, but they help to clarify issues that have been at the heart of a policy debate over the reach of the Stark law, a law intended to prohibit referrals to a business that has a financial relationship with the referring provider under Medicare. That prohibition applies to most in-office ancillary services, but there a few exceptions: physical therapy is one of them. APTA has made elimination of these exceptions one of its public policy priorities.

The new study also fills in some of the gaps left in a 2014 report from the US General Accountability Office (GAO), which looked at self-referral for physical therapy across all health conditions under Medicare. That report found a higher rate of referral to physical therapy (and fewer physical therapist services received) among self-referred cases, but was limited in its scope. Authors of the new study cite a number of "deficiencies" in the report, including its focus only on elderly patients, and the lack of any analysis of the types and quality of physical therapist services rendered.

“The results of this study further confirm what APTA has firmly believed for years now,” said APTA President Sharon L. Dunn, PT, PhD, OCS, in an APTA news release. “Referral for profit leads to health care practices that benefit the provider and remove the focus from where it should be; the patient. APTA has long advocated for the elimination of referral for profit for physical therapist services from health care.” 

For their part, the study's authors keep the focus on the ways in which the quality of physical therapy services differ between self-referred and non-self-referred episodes.

"An important contribution of this study is the finding that the composition of physical therapy services rendered to [LBP] differs between self-referring and non self-referring practices," authors write. "The care provided by independent therapists is comprised of more active, hands on treatments which appear to be appropriate in light of empirical evidence showing that passive procedures are not effective treatments for LBP."

The study was funded in part by the Foundation for Physical Therapy and the National Institute on Aging.

PREVENTING LOW BACK PAIN DURING PREGNANCY

http://www.moveforwardpt.com/PatientResources/VideoLibrary/detail/back-preventing-low-pain-in-pregnancy

Attached above is a wonderful link provided by the APTA, or the American Physical Therapy Association, for women just like you to help prevent/manage back pain during pregnancy! Let us know what you think! 

UTILIZING EVIDENCE-BASED PHYSICAL THERAPY FIRST HELPS TO LOWER COST OF LOW BACK PAIN

According to the APTA, If you have low back pain, you should get evidence-based physical therapy right away. Otherwise, your costs are likely to go up, along with the potential use of opioid medications, spinal injections, surgery, and other treatments.

That’s according to the results of an award-winning study published in BMC Health Services Research that reviewed 122,723 Military Health System patient records (Implications of early and guideline adherent physical therapy for low back pain on utilization and costs – April 9, 2015).  

Researchers divided patients into 4 groups: those who received physical therapy within 14 days of a physician visit; those who received physical therapy after a wait of at least 14 days; those who received "adherent" physical therapy (reflecting evidence-based guidelines); and those who received "nonadherent" physical therapy.

The study contributes to a growing body of evidence demonstrating that early physical therapy for low back pain lowers costs, and that beginning low back pain treatment with advanced imaging increases costs.

"Physical therapy as the starting point of care in your low back pain episode can have significant impact," said lead author John D. Childs, PT, PhD, in a PT in Motion News article about the study ("Early Guideline-Based Physical Therapy Results in Health Care Savings for Patients With LBP" - April 9, 2015). "Receiving physical therapy treatment that adheres to practice guidelines even furthers that benefit."

TA MUSCLES AND BACK PAIN

WHAT IS IT?

You may not have heard of the transverse abdominis (TA) muscle, but it's an important muscle that acts as a stabilizer of the low back and core muscles. It is one of the main core stabilizing muscles of the lumbar spine. A weak TA is often indicated in low back pain. If you're looking to alleviate lower back pain, strengthening your TA muscle may be the ticket.

WHERE IS IT?

The TA is the deepest layer of abdominal muscles and runs between the ribs and the pelvis, horizontally from front to back. When activated, the TA muscles create a deep natural "corset" around the internal organs and lumbar spine. This activation flattens the abdominal wall, compresses the viscera (internal organs), supports the internal organs and helps expel air during forced exhalation. One major function of the TA muscles is to stabilize the spine and pelvis during movements that involve the arms and legs.

WHAT HAPPENS WHEN YOUR TA ISN'T BEING UTILIZED

If the TA muscles are weak, the abdominal wall will begin to bulge forward and the pelvis may rotate forward and increase lordosis (inward curvature) in the spine. This can result after pregnancy and may also be associated with weight gain or lack of exercise.

A recent study shows that weak TA muscles may be to blame for lower back pain. Lack of strength, in this case, is a lesser concern compared to an inability to activate. Decrease in activation is caused by sedentary lifestyles, where the brain essentially "shuts off" the TA in response to lack of use.

When activities are added into sedentary lifestyles, like gardening or dog walking, back pain is the result because the brain-musculoskeletal relationship does not recognize the difference in activity until afterward.

This reason is essentially the same concept behind soreness. The body can complete many activities, some will just simply cause soreness because the body isn't used to being challenged in that manner. 

Add in an activity like gardening or dog walking, and the brain will not recognize the body needs the TA until even months down the road.  This is the main difference between muscle soreness and back pain related to TA activation; many muscles on the extremities are operationally responsible for specific movements - for example, the elbow is mainly bent by the biceps. The TA is not responsible for core strength - the obliques and rectus abdominus are more useful as far as actual strength goes. However, the small aspect of keeping the viscera stable and contained, as well as keeping the pelvis and spine stable, cannot be done without the TA.  This will eventually result in back pain, and the back pain will continue until the TA is retaught to fire. It is for this reason that it is just as important to train the brain in activation as much as it is in training the muscle, itself. 

DOES THIS SOUND LIKE YOU?

Talk to your doctor about chronic back pain, and make sure to mention any changes in your activity levels or daily routines.  Ask them to recommend you to Champion Performance and Physical Therapy, as that is a sub-specialty of ours. It takes diligence to train your body to activate and strengthen your TA, but with the right guidance, it is possible to continue your activities pain-free. 

DOES BAD POSTURE = BACK PAIN?

First thing's first:

Bad posture does not necessarily imply back pain.  Some people are naturally born with protracted, rounded shoulders, hyperlordosis, or hyperkyphosis (excessive curvatures) of the spine. When this happens, the body makes adjustments to accommodate the forces that act on it during daily activities, such as sitting, standing, and lying down. 

Next question:

Without any physical limitations or deficiencies, however, bad posture being correlated with back pain brings a question similar to that of "what came first - the chicken or the egg?"  You must decide which scenario better fits your situation.

Back pain can cause a negative shift in posture to accommodate and relieve the pain - back pain comes first.

OR

Poor posture, including slouching, rounded shoulders, head and neck, cause increased stress on the muscles of the back, causing pain. 

Thirdly:

Bad posture, without any anatomical limiting factors, is typically caused tightness of certain muscles, mixed with weakness of others.  In addition to muscular deficiencies, there are likely going to be some joints that are misaligned within the spine.

Let's start with the muscles.

A mixture between hip flexor tightness and pectoral tightness, along with scapular weakness and core weakness are 8/10 musculoskeletal cause of poor posture.

Tightness in these areas are more likely to come from more stagnant lifestyles; which doesn't necessarily mean sedentary, more along the lines of many activities may cause similar positions. 

For example: a business man who works a desk job is also an avid cyclist. Sitting in a desk chair all day, then cycling many miles in a hunched position, then come home to eat dinner seated, unwind seated, would mean their lifestyle is positionally stagnant. 

In other words, you may be an active person living an decently active lifestyle, but if you sit and think about it, many of the activities you partake in involve the same anatomical positions. Keep in mind, some are more prone to problems related to this than others. 

Misaligned Joints:

Almost every single muscle of the body inserts onto a bone. Keep in mind, your skeleton is simply a lever system controlled by the muscles. Your bones don't move, your muscles pull on your bones to make them move. 

So with that in mind, picture a person with half of their muscles tight, and half of their muscles weak. All of those tight muscles are pulling hard on their bony insertion points, and when their muscular counterparts are too weak to keep the bones in place, the joints will become misaligned. This can cause over-stretching of the weaker muscles, and nerves to get pinched underneath the tighter muscles.

Ergo, how bad posture can lead to back pain. 

Lastly: 

How do you naturally combat this?

1. Ensure good joint alignment.

When you bend down to put a dish away, make sure you lower your body with your legs, and activate those glutes.  They're relatively speaking to strength, some of the most influential muscles in your body. Keep your knees over your ankles, and shoulders over your knees when squatting down.

2. Ensure good core activation.

Make sure when lowering your own body down into a squat, picking/lifting any objects, and even sitting and standing, that you are keeping your core tight. Not sure what this means? Lay down on your back, look down at your belly button. Next, find your hip bones - these mark the start of the front of your thighs. Place two fingers just on the inside of each of those hip bones and say "SSS" short and quick.  Feel that contraction? That's your core. Keep it contracted. The stronger it is, the less back pain you'll have. 

3.  Work on your movement.

Be very aware of the movements you perform on a daily basis that cause pain or discomfort. Your physical therapist will want to know, and they'll give you exercises to relieve the tension on some muscles, and to strengthen others. 

4.  Vary your posture. 

Mix it up! Sit at a desk 8 hours per day? Stand every couple.  It's best for brain function to take a 5 minute break every hour, and it's best for musculoskeletal function to change positions every 20 minutes or so.  This does not mean sitting to standing, maybe just sitting back in your chair to sitting forward with your hands or elbows on your desk. Most people slouch in their chairs without even noticing, so make sure to adjust your position frequently if you plan to stay seated throughout most of your day. Another option that helps from slouching is avoiding using the backrest of the chair. 

Questions? Call or set up an appointment with our wonderful staff - we're all specialized in problems such as this!

 

PREVENTING BACK PAIN AT HOME AND AT WORK

Almost everyone will experience back pain at some point in their lives. Back pain varies from one person to the next. It can range from mild to severe, and can be acute or chronic, depending on the cause.

Preventing all back pain may not be possible. We cannot avoid the normal wear and tear on our spines that goes along with aging. There are, however, things we can do to lessen the impact of low back problems and adjust aspects of our daily routine to better prevent acute injuries from occurring. 

Having a healthy lifestyle is the first way to prevent back pain. 

  • Exercise

Combine exercise, like walking or swimming, with specific core-strengthening exercises to keep the muscles in your back and abdomen strong and flexible.

  • Weight

Maintain a healthy weight. Being overweight puts added pressure on your spine and lower back.  Quick weight gain without adjusting your daily exercise regime will usually cause problems in the low back, as the muscles require time to strengthen as your weight increases (body builders, pregnancy, etc.)

  • Avoid Smoking

Both the smoke and the nicotine cause your bones, and more specifically, your spine to age faster than normal.  Smoking is a known catalyst of osteoporosis, which is will cause weakening of the vertebrae. 

  • Proper Posture

Good posture is important to avoiding low back problems. How you stand, sit, and lift things has an increasing effect on your spine health.

  • Drink Plenty of Water

Water is required for healthy function in every cell of the human body.  The spine, like all other joints, requires lubricant to allow pain-free movement. Drinking enough water each day can increase your body's natural lubricant production. 

Guidelines for Proper Lifting

  • Plan ahead what you want to do and do not be in a hurry.
  • Position yourself close to the object you want to lift.
  • Separate your feet shoulder-width apart to give yourself a solid base of support.
  • Bend at the knees.
  • Tighten your stomach muscles.
  • Lift with your leg muscles as you stand up.
  • If an object is too heavy or is an awkward shape, do not try to lift it by yourself. Get help. 

Picking Up a Light Object

To lift a very light object from the floor, such as a piece of paper, lean over the object, slightly bend one knee and extend the other leg behind you. Hold on to a nearby chair or table for support as you reach down to the object, as necessary.

Picking Up a Heavy Object

Whether you are lifting a heavy laundry basket or a heavy box in your garage, remember to get close to the object, bend at the knees, and lift with your leg muscles. Do not bend at your waist.

When lifting luggage, stand alongside of the luggage, bend at your knees, grasp the handle and straighten up.  Do your best to keep your stomach tight while lifting the object.  This anatomical act of checks-and-balances will allow your core to split the opposing force between both sides of the body, and therefore, lessening the stress on the back, alone.  The checks-and-balances system includes the quadriceps and hamstrings, the biceps and triceps; or in other words, muscles that pull the body in the opposite direction from the other. 

Holding An Object

While you are holding the object, keep your knees slightly bent to maintain your balance. If you have to move the object to one side, avoid twisting your body or leaning backward. Point your toes in the direction you want to move and pivot in that direction. Keep the object close to you when moving, and again, keeping your stomach tight will lessen the stress on the low back and naturally force you to keep from leaning backward. 

Placing an Object on a Shelf

If you must place an object on a shelf, move as close as possible to the shelf. Spread your feet in a wide stance, positioning one foot in front of the other to give you a solid base of support. Do not lean forward and do not fully extend your arms while holding the object in your hands.

If the shelf is chest high, move close to the shelf and place your feet apart and one foot forward. Lift the object chest high, keep your elbows at your side and position your hands so you can push the object up and on to the shelf. Remember to tighten your stomach muscles before lifting.

Supporting Your Back While Sitting

When sitting, keep your back in a normal, slightly arched position. Make sure your chair supports your lower back. Keep your head and shoulders erect. Make sure your working surface is at the proper height so you don't have to lean forward. Once an hour, if possible, stand, and stretch. Place your hands on your lower back and gently arch backward.

Move Often

Allow yourself plenty of opportunities to move and stretch.  The recommended break time for students is 5 minutes for every 30 minutes studying, or 10 minutes for every 60 minutes.  It's proven to improve cognitive function and memory, as well as relieve tension in the muscles of the body. Think about it - how many times have you been "in the zone" writing a letter or typing an email, and when you press that send button, you feel your shoulders, neck, and back relax?  That tension over time will cause tight muscles.  When the muscles are tight, they pull on the bones.  When they pull on the bones so much, they can move the bones slightly out of place - but slightly is enough to feel it. Some companies are now allowing employees to inquire about a standing desk - one that can raise if you'd prefer to stand for part of your day. Make inquiries with your HR department if this interests you!

Need Help Adjusting?

 If you suffer from acute or chronic back pain, talk to your doctor about the possibility of starting physical therapy with us at Champion Performance and Physical Therapy. If some of these qualities sound oh-too-familiar and think you could use some overall strengthening exercises for your core to simply improve your quality of life, you are welcome to contact us and we'll see if you are eligible to come in we can see if you qualify to come in without a prescription from your doctor for a simple evaluation and exercise plan. 

Source: http://orthoinfo.aaos.org/topic.cfm?topic=A00175