Physical Therapist’s Role in Lower Back Pain

Low back pain (LBP) is a prevalent health issue affecting millions of people worldwide, with significant implications for individuals’ quality of life and economic burden on society. In fact, according to the World Health Organization (WHO), low back pain incidence is increasing. Referencing 2020 data, 1 in 13 people (which equates to 619 million people worldwide) have experienced LBP. This represents a 60% increase from 1990.¹ While increases in prevalence are certainly concerning, research¹ has shown us that it’s a relatively small subset of LBP cases that impact society the most: Chronic Low Back Pain. Defined by the WHO as “pain that lasts for more than 3 months that is not due to an underlying disease or other condition,” this subset (often estimated between 10-20% of low back pain cases) accounts for the majority of costs, office visits, missed work, and disability. With such an increase in LBP prevalence, healthcare providers must focus not only on the management of chronic low back pain but also strive to prevent acute cases from transitioning to chronic cases.

Considerations for Primary Care Providers

For years there has been acknowledgement that LBP is a major concern among healthcare providers. Unfortunately, there hasn’t always been a consensus on how best to intervene. As providers strive to provide patients with evidence-based medicine, Clinical Practice Guidelines (CPG) have been developed to guide clinicians in their approach to patient care. Created by systematically reviewing quality research, CPGs serve to provide healthcare providers with guidance on the best courses of action to improve outcomes. One such CPG was published in the Annals of Internal Medicine in 2007², and specifically outlined how primary care providers can enhance the care they provide patients with LBP. The guidelines cover various aspects of low back pain, including diagnostic approaches, appropriate use of imaging studies, pharmacological interventions, non-pharmacological therapies, and when to consider surgical options. Key recommendations include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, education, and some manual therapies as first-line treatments for managing LBP. Additionally, the CPG outlines that imaging studies should be reserved for specific clinical indications (outlined as ~15% of LBP cases).

In addition to the 2007 CPG recommendations, the WHO published their own guidelines in 2023 regarding evidence-based recommendations for those experiencing chronic low back pain. These interventions include: education programs that support knowledge and self-care strategies, exercise programs, physical therapy, psychological therapies, and medicines like non-steroidal anti-inflammatories.

Considerations for Physical Therapists

As you likely noted in the recommendations above, physical therapy is an intervention encouraged for patients experiencing both acute and chronic low back pain. Physical therapists have long provided care to patients with LBP, leveraging a variety of treatment interventions. That said, not all interventions are created equal. In an effort for the profession to provide high-quality, evidence-based care to all patients with LBP, CPGs for have been developed to guide physical therapist’s decision-making. As of 2021, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) published a revised CPG outlining interventions for LBP that were supported by research. Key recommendations within the CPG included manual therapy (including thrust/non-thrust approaches and soft tissue mobilization), exercise (ranging from core stabilization training and aerobic training to aquatic therapy), and education (with an emphasis on what causes low back pain, what makes low back pain worse or better, and strategies to help manage low back pain, such as how to safely remain active and pace activities.³  By levering these evidence-based approaches, therapists can improve outcomes, and hopefully prevent acute cases from transitioning to chronic LBP.

Low Back Pain and Worker’s Compensation

As outlined by the Bureau of Labor Statistics⁴, LBP is the most commonly reported work-related musculoskeletal disorder across a variety of industries. Considering the prevalence, focus must be given to determining treatment approaches that improve outcomes, decrease disability, and reduce costs.  Physical therapists, as outlined in prior paragraphs, are in a prime position to intervene and treat injured workers with LBP. In fact, there’s even been research to show that the sooner injured worker’s start physical therapy, the better. As outlined by a 2020 research report from the Workers Compensation Research Institute, getting physical therapy for low back pain within 14 days of injury is associated with significant reductions in the use and costs of medical services such as MRIs, opioid prescriptions, pain management injections, and low back surgery⁵.  The report demonstrated the starkest contrasts between those injured workers who receive PT early (within 3 days) and those who receive PT late (30 days after the Date of Injury (DOI)).  For injured workers receiving PT 30 days after the DOI, there was a 47% increase in the likelihood of receiving an MRI, a 46% increase in opioid use, a 29% increase in injections, and an 89% increase in surgery. It should be assumed that this increase in medical interventions would likely drive up the total cost per claim. The report confirmed this assumption, highlighting that the average payment per claim was 24-28% higher compared to those injured workers receiving early PT.

Summary

LBP prevalence is on the rise. While healthcare providers will be hard-pressed to prevent low back pain from occurring in the first place, there is ample opportunity for us to leverage the research to reduce the probability of acute cases transitioning to chronic cases. By leveraging research-supported Clinical Practice Guidelines, primary care providers can ensure patients are quickly offered treatments that are shown to be effective (like physical therapy). Therapists can leverage manual therapy skillsets and exercise prescription to reduce symptoms and promote return to activity. Additionally, due to the time and frequency that therapists interact with patients, they can spend ample time on education (which the literature confirms is effective at improving outcomes).

Finally, therapists are in a prime position to assist injured workers and worker’s compensation stakeholders. By intervening early, therapy can reduce costs, limit invasive interventions, and improve outcomes. When it comes to PT for injured workers, the Workers Compensation Research Institute report summarized it best: “The findings of our study support the value of ordering PT early rather than late, suggesting that clinicians and payors should be encouraged to work proactively to remove barriers to early [physical therapy].”

To learn more about how Upstream Rehabilitation and our family of brands can assist with Workers’ Compensation and how physical therapy plays an effective role in helping injured workers return to work, contact our Workers’ Compensation team today!

1. https://www.who.int/news/item/07-12-2023-who-releases-guidelines-on-chronic-low-back-pain
2. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008 Feb 5;148(3):247-8]. Ann Intern Med. 2007;147(7):478-491. doi:10.7326/0003-4819-147-7-200710020-00006
3. https://www.jospt.org/doi/epdf/10.2519/jospt.2021.0508
4. https://www.bls.gov/opub/ted/2018/back-injuries-prominent-in-work-related-musculoskeletal-disorder-cases-in-2016.htm
5. https://www.apta.org/news/2020/09/21/workers-comp-lbp-report