Managed Physical Medicine

Not-so-alternative Care: Conservative Low Back Pain Treatment Gains Acceptance

Exercise therapy and acupuncture are becoming more mainstream treatment options for low back pain. What’s driving this change?

This blog is part 1 of a three-part series titled “How We Treat Low Back Pain: Emerging Research, Frameworks and Care Models.”

In the past, when the term “alternative care” was thrown out in a clinical setting, it meant something wild and non-mainstream. However, the tide is turning in the world of musculoskeletal treatment, and what was once considered “alternative” or “complementary” is in many cases becoming first-line.

Why are options like exercise therapy and acupuncture gaining mainstream adoption as treatment for low back pain (LBP)? In this blog, we examine the forces driving conservative care for LBP and their effects on workers’ comp.

The Downfall of Opioid Treatment

According to a 2015 BMJ article, the rates of opioid prescribing in the United States and Canada are two to three times higher than in most European countries – and more than half of regular opioid users report low back pain. Rates of addiction and overdose-related mortality have risen in tandem with prescription rates, leading the opioid crisis to be named a national public health emergency.

To support a nationwide shift in prescribing habits, a body of research is growing to demonstrate that conservative care (i.e., physical therapy) as first-line treatment for LBP can improve patient outcomes. The evidence is building, but how do we ensure this data filters back down to providers to inform their recommendations for LBP treatment?

Revised Treatment Guidelines

Several factors go into the treatment choices of individual providers; however, practitioners look to evidence-based guidelines as a framework for daily care decisions. Recent research on the efficacy of conservative care treatment, including the role of physical activity, is shaping the revisions of LBP treatment guidelines and recommendations nationwide. The American College of Physicians updated its clinical practice guidelines in February 2017 to promote noninvasive treatment for LBP. The revisions prioritize nonpharmacologic options for the treatment of subacute and acute low back pain as well as chronic LBP. The recommendations for chronic LBP include exercise, multidisciplinary rehabilitation, acupuncture and mindfulness-based stress reduction – further nudging these formerly complementary practices toward the frontline of care.

Likewise, shake-ups are happening among federal- and state-funded insurance plans. Some, like Medicare’s wide-reaching regulation to deny payment for long-term, high-dose narcotics, affect the treatment plans of chronic back pain sufferers, among others. Other regulations are more narrowly focused. For example in Oregon, the state’s Medicaid equivalent, the Oregon Health Plan, reformed its policy after realizing over half of its back patients were receiving narcotics. The new policies, which apply to all back conditions, promote physical therapy, chiropractic and other complementary treatments over painkillers and surgery.

A Word on Workers’ Comp

Is the workers’ comp industry undergoing the same level of reform in its approach to LBP treatment? Signs point to yes. As more studies emerge indicating the efficacy and cost-effectiveness of physical therapy as first treatment, payers and providers are aligning in its favor. In some states, this preference is being baked into workers’ comp policy. In 2017, the Ohio Bureau of Workers’ Compensation (BWC) approved a rule promoting conservative therapy for workers with lower back injuries in lieu of surgery and opioid use. The new policy requires workers to undergo a minimum of 60 days’ comprehensive conservative care, including PT or chiropractic care and rest among other non-surgical treatments, before considering a surgical option. Similarly, Washington State launched a pilot program last year to use acupuncture to treat injured workers with low back pain, with the hope that acupuncture coverage for LBP would extend to other conditions in the future as well.

There is still much work to be done in shifting the mindset of a quick-fix society to embrace a model of LBP treatment that promotes gradual improvement, patient involvement and downstream gains. But given the dangers of opioid prescription, payers, providers and employers seem to agree on one thing: it is, undeniably, time for change.