A recent study (ImPact Back Study) published in the Annals of Internal Medicine demonstrated that low back pain sufferers had statistically significant improved treatment outcomes, at a lower cost when the case was classified as either low, medium or high “risk” for persistent disability and received a standardized treatment method for that level.
Specifically, low-risk patients received a single session of intervention comprising assessment, education and support for self-management.
Medium-risk patients receive physical therapy interventions that focus on reducing pain and disability, encouraging physical exercise and facilitating early return to work.
Meanwhile, high-risk patients receive “psychologically informed” physical therapy that integrates cognitive behavioral techniques with traditional physical therapy to reduce pain and disability, improve psychological functioning and facilitate self-management.
Other benefits associated with stratified care as compared with usual care included significantly more risk-appropriate referrals to physical therapy, a 39% relative reduction in sickness certifications, a 50% relative reduction in time off work sick, a decrease in use of non-opioid medications and concurrent increase in use of mild opioids.
This study was done in the U.K., so there are likely differences in the protocols for treating low back pain compared to the U.S. It is interesting that common procedures in the U.S. for “high risk” low back pain such as facet injection and decompression surgery were not mentioned. Perhaps it is their experience that such procedures have not demonstrated efficacy in resolving low back pain, and that psychotherapy combined with traditional physical therapy is more effective.
The bottom line is that, if you have low back pain, an accurate diagnosis is obviously very important. Granted, in many cases the origin is difficult to pin down, it is prudent to take into consideration the possible role of the patient’s psychology and use appropriate interventions like CBT. Defaulting to opioid and non-opioid drugs may be counterproductive, as addiction and liver and kidney toxicity is always a risk.