Is physical therapy appropriate for all patients with low back pain? Is it possible to figure out which patients will benefit and which will not? Over the past decade medicine has moved into and era of cost effectiveness of treatment. In other words, it is a much better strategy both medically and financially to provide the most effective treatment for each medical condition. Obviously, the more common the medical problem the easier it is to study and determine what works and what does not. Physical therapy has been a mainstay of treatment for low back pain for decades. But as we have learned about medicine over the years is that things are not always as they appear to be. In Europe the analysis of cost effectiveness for various treatments of low back pain from surgical interventions to medication usage to physical therapy has been going on for the past few decades. Over the past 25 years, much low back pain research has focused on ways to predict which patients are going to progress to chronicity, with the goal of early intervention with targeted treatments that minimize the impact of the condition.
In a recent study by Foster and his colleagues categorized low back pain patients into three categories based on risk of developing chronic low back pain: high, medium and low risk. The medium and high risk individuals were referred to physical therapy for specific treatment protocols. The protocols emphasized maintaining function and avoiding time off work (medium- and high-risk patients) and the use of psychologically-informed physical therapy (high-risk patients)
The low-risk patients were provided advice on activity and medications, reassurance that further treatment is not necessary or beneficial, and that their prognosis is good; for medium- and high-risk patients, the patient ws referred to a trained physical therapist. The protocol for the medium-risk patients (focus on restoring function, targeting physical signs/symptoms, and using exercise and manual therapy) is the usual standard of care delivered by many physical therapists treating patients with low back pain. The high-risk protocol (psychologically informed physical therapy which uses elements of cognitive-behavioral therapy and incorporates patients beliefs, attitudes, and emotional responses into patient management), is relatively uncommon and not known or practiced by most physical therapists in practice today. In psychologically-informed physical therapy, the physical therapist is not becoming a psychologist, but rather using elements of cognitive-behavioral therapy and biopsychosocial approaches to enhance the usual care approach. In the high risk treatment it does not appear that modalities such as traction, massage, and electrotherapy were not used. Modalities such as these have never been shown to be effective to the slightest degree in the treatment of low back pain. Furthermore, it has been shown that treatment that is primarily passive in nature can lead to greater impairment and longer recover periods.
In conclusion, physical therapy appears to be useful in low back pain but it is limited to the person that is at high risk of developing a chronic pain. The therapy protocol should incorporate a cognitive behavioral approach that includes a discussion with the patient about their attitudes and beliefs and emotional responses to their back pain problem.
- Foster NE, Mullis R, Hill J, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back):a prospective population-based sequential comparison. Ann Fam Med. 2014;12(2):102–111.
- Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011;91(5):820–824.
- Foster NE, Delitto A. Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice—challenges and opportunities. Phys Ther. 2011;91(5):790–803.