Chronic Low Back and Neck Pain: An Epidemic Out of Control
May 11, 2012
You would be hard-pressed to find an insurer in the United States today who isn’t looking for ways to reduce healthcare costs without compromising the quality of care. Cost centers associated with chronic lower back and neck pain are a good place to start. At $100 billion annually, back and neck pain treatment interventions are the sixth most costly medical expense, and the number one surgical cost center in the healthcare system.
The following are three primary reasons for spiraling costs:
- Back pain and neck pain are common
- There is a huge diversity and lack of sustained success in the treatment of chronic back and neck pain
- The prevailing “fee for service” approach encourages healthcare providers to continue to treat patients without measuring or holding those providers accountable for patient outcomes
Many people are afflicted by back pain and neck pain…
Nearly everyone at some point has back pain that interferes with work, recreation, or daily routine. Back pain affects about 80 percent of adults at sometime in their lives. About 50 percent of people have experienced neck pain.
Back pain is:
- The #1 reason for lost work days
- The #2 most common reason for doctor visits - second only to the common cold
- The #2 leading cause of disability
Varied treatments from diverse professionals lack sustained success…
The sheer number and different types of healthcare providers that treat chronic back and neck pain - many with their own unique approaches - suggests that we do not have a good understanding of this very common and expensive problem.
The wide variety of diagnostic tests that are available - ranging from a simple x-ray to 3D magnetic resonance imaging (MRI) - can cost from $500 to more than $3,000 depending on the location and provider. However, it has been estimated that less than 20 percent of patients can be given a precise diagnosis.
Patients cycle through multiple protocols delivered by physicians, chiropractors, and therapists. There are more than a dozen therapeutic approaches from medications to chiropractic adjustments, physical therapy, and surgery - all lacking objective measures to quantify their effectiveness for the patient with persistent back and neck pain.
There are arguments as to which approach is best. Most of these debates are meaningless since there are no common measures within the spine healthcare community by which to gauge success.
“Fee for Service” approach makes the problem worse…
Millions of healthcare dollars are spent each year on ergonomic modification, sophisticated diagnostic capability, multiple treatment(s), surgical approaches, case management, and administrative control. Yet, chronic back and neck pain remains one of the most difficult and frustrating health challenges for doctors, therapists, patients, and insurers.
In spite of the increased sophistication of technology and thousands of scientific articles on this topic, none of the above - whether diagnostics or healthcare professionals - have reduced back-care costs. On the contrary, costs related to back-care continue to increase.
Varied and repeated diagnostic tests contribute significantly to the problem. Too often diagnoses are directed more towards reimbursement than the underlying patho-mechanical origin of the back or neck pain; and it is not only the doctors who suggest multiple tests.
Often patients demand these tests as the public consciousness now believes sophisticated technology exists that can look inside the body to uncover the cause of their elusive and nagging back or neck pain. When physicians do not order these tests, patients will often seek other providers who will. Measurement is imperative to successful treatment…
Measurement is the key to more effectively addressing the treatment of back and neck pain. Without it, the conversation - no matter how prolonged or filled with professional jargon - is simply opinion based on experience. This is not necessarily a bad thing; but it does not lend itself to predictable and consistent outcomes.
Before beginning any rehabilitation strengthening program, the patient should be quantitatively evaluated to determine pain, strength, and range of motion. Knowing the back and neck pain patient’s functional baseline strength permits the healthcare professional to prescribe safe, effective, measured, and meaningful progressive resistance strengthening.
Back pain can be treated successfully by strengthening the muscles of the lumbar and cervical spine…
Chronic pain leads to inactivity. Inactivity leads to stiffness and less functional capacity. Stiffness produces weakness. Weakness produces chronic pain. What is the point? Chronic pain is self-perpetuating.
Breaking the cycle of chronic back pain requires strengthening the spine as well as the elements of the spine that are thought to be the main cause of the pain.
There is no way to increase function to the body without strengthening the specific muscles responsible for movement and posture. This is true in all joint/muscle structures; it is particularly true in the spine. This requires strengthening the lumbar and cervical spine in an isolated fashion. Fortunately, the technology exists to target, measure, isolate, and then strengthen the weakened muscles of the spine.
Strengthening these back muscles will have the greatest impact in reducing pain, increasing quality of life, and in many patients, protecting the back from future injury. However, clinical research has demonstrated that when the neck or back muscles are isolated and exercised correctly, the healing process for these areas is greatly enhanced. Yet, the vast majority of physical therapies for the treatment of back and neck pain concentrate on core muscles of the trunk, including almost every associated muscle group - except the specific spinal muscles themselves.
Back muscle strengthening can be compared to the commonly understood model of the knee…
Progressive exercise is only helpful if performed with the appropriate muscles. The idea of strengthening the muscles of the trunk to the exclusion of the spinal extensor muscles makes little sense.
Consider the corollary of the functional restoration of the knee following injury or surgery. It is common practice to strengthen the knee capsule and supportive muscles. This prevents scar tissue from developing which would otherwise cause less mobility and greater pain.
It would be inconceivable to strengthen the hamstrings (muscles on the back of legs) to the exclusion of thigh muscles when rehabilitating the knee. Strengthening the muscles that support the knee with forward and back movements - in particular thigh (quadriceps) muscles - increases stability of the knee capsule and reduces risk of future injury.
As with the knee, strengthening the low back and neck extensor muscles is just as important to protect their motion segment (joint complex) as strengthening thigh extensor muscles to decrease the risk of future injury in the knee.
The low back moves in exactly the same plane as the knee. While the back is a bit more complex, forward and backward movements (flexion and extension) are safe, posing no risk for further injury.
Forward and backward movements of the spine increase the flow of blood to the area of injury and provide good nutrition and fluid to the spinal discs. This motion should be encouraged. If these movements are painful, they can be modified to accommodate the individual patient. Safety and the appropriate levels of strengthening are critical.
During and following treatment, the patient should be reevaluated to determine progress. The yardstick (strength and range of motion test) remains the same. The objective change in patients’ function and pain compared to where they began determines success or failure.
Measurement along with target muscle isolation can become the new standard in the treatment of low back and neck pain…
With the cost of healthcare exceeding 17 percent of GDP, no matter what happens in Washington, the face of healthcare is irrevocably changing.
In the treatment of chronic neck and back pain, it will continue to be more and more incumbent on healthcare providers to deliver a product that produces a service that is dependable, predictable, and reproducible.
In the past, the subjective/costly way that chronic back and neck pain therapy has been performed in this country has been acceptable. Today, advanced treatment options (expressly those that isolate and strength specific back muscles) which are aligned with measurably improved patient outcomes and reduced costs, offer patients and insurers a better choice.
In the arena of spinal rehabilitation, measurement-driven therapy should not just become the standard of care but demanded by those who are paying the bill.
About The Author
Dr. Thomas E. Dreisinger, Ph.D./FACSM is the Executive VP of Outcomes Research for Pure HealthyBack, Inc. www.purehealthyback.com. Dr. Dreisinger’s background spans 30 years of clinical experience in rehabilitation, orthopedics, and physical medicine. He has taught at the university level, and presented scientific papers both in the United States and abroad on topics related to the management of the chronic back pain patient and clinical outcomes. He has published articles in numerous biomedical journals including Spine, Orthopedics, Journal of Rheumatology, Sports Medicine, Paraplegia, and the Journal of Cardiac Rehabilitation. Email him at: firstname.lastname@example.org