Covid-19 and Its Impact on the Prevalence and Treatment of Low Back Pain

By: Cheryl “Chae” Dimapasoc, PT, DPT;  OptimisPT Director of Implementation and Compliance

Low Back Pain (LBP) affects at least 80% of us at some point in our lifetime and 20-30% of us at any given time, which is roughly 33 million individuals.  The yearly expenditure for this condition is approximately $100 billion per year in direct and indirect costs and is growing at about 8% per year (Barnes, 2020).  In addition, once diagnosed, there is evidence of excessive imaging and surgery for low back pain in the United States (Carey 1996), and many experts believe the problem has been “over medicalized” (Hadler 1998) by treating it with expensive, invasive interventions that are of questionable value in terms of cost-effectiveness (Deyo 2001, Weinstein 2006).  These interventions, including surgery, injections, and long term pharmaceutical use are generally ineffective, incur more risk, and are significantly more costly. Often, patients who receive these aforementioned interventions end up back in the emergency department (Deyo 2009).

How Covid-19 Has Impacted Access to Care for Low Back Pain

The COVID pandemic has significantly changed how patients are accessing healthcare to address their low back pain.  Much of the time patients with intense back pain access the Emergency Department (ED) to address their symptoms.  A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ED, with more patients being admitted via this route each year.  The study found that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.  Between March 29-April 29, 2020 compared to the same timeframe in 2019, ED visits for reasons other than COVID-19 related symptoms declined 42%.  The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public.  Persons who use the ED as a safety net because they lack access to primary care and telemedicine might be disproportionately affected if they avoid seeking care because of concerns about the infection risk in the ED.

With hospitals beginning to open up again for elective surgeries and individuals still hesitant to access the ED for care, regular appointments for common conditions are often weeks or months out.  The CDC recommends that telehealth services should be optimized, when available and appropriate to participate in physical therapy, occupational therapy, and other modalities as a hybrid approach to in-person care for optimal health (CDC June 28, 2020).

Findings from individual studies suggest that telehealth intervention, when used as an adjunct to usual care, appears to optimize the effects of usual care in patients with recent onset of LBP symptoms.  Furthermore, telehealth was superior to a control intervention for improving quality of life regardless of duration of LBP symptoms or follow-up length.

Telehealth as an Adjunct to In-Person Care

A study on hospital readmittance reported that 49% of participants who received Telehealth were likely to be readmitted to the hospital compared with 67% of those who did not receive the Telehealth treatment. (Barnes, May 2020)

Due to the nature and progression of low back conditions, there should be a greater attempt in orthopedic rehabilitation models to prevent acute low back pain patients from becoming chronic patients with greater disability.  Research on early intervention clearly indicates that high-risk acute LBP subjects who received early intervention displayed statistically significant fewer indices of chronic pain disability on a wide range of work, healthcare utilization, medication use, and self-reported pain variables relative to the high-risk subjects who did not receive such early intervention.

Specific Validity ElementTelehealth Validity
Detection of pain with specific movementsHigh validity
Identifying the quality of lumbar movementModerate validity
Postural analysisPoor validity
Identifying reasons for limitationsPoor validity

The study concludes that “important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting”. (Truter, P., Russel, T and Fary, R. ‘Low Back Pain via Telerehabilitation in a Clinical Setting’ Telemedicine and e-Health 20(2): pp. 1-12)

Patients are classically poor performing partners in their own healthcare.  They often do not fully participate, nor take responsibility for their own health.  Compounding this problem is the nature of our healthcare system, which fragments continuity of care.  As compliance research shows, between 45-70% of patients are noncompliant with their physical therapy prescribed exercises.  This new field of Telehealth management promises to increase patient exercise adherence while offering physiotherapists a method to support patient self-management between face-to-face sessions. (WHO (2003) Adherence to Long Term Therapies. Geneva: Evidence for Action)

Is Telehealth Effective for Low Back Pain?

Mechanical low back pain is the most common type of low back pain and makes up 97% of all types of low back pain.  Non-specific low back conditions, such as lumbar sprain or strain caused by acute injury, repetitive trauma, and poor posture during activities, make up greater than 70% of all cases (Deyo 2001).

These non-specific low back conditions are precipitated in most patients by deconditioning and poor strength of the deep stabilizing muscles of the spine, the “core” muscles (Richardson 1999, Hides 2001).  Of these mechanical causes, 10% are due to age-related degenerative changes in disks and facets, 4% are due to herniated disks, 4% are due to osteoporotic compression fractures, and 3% are due to spinal stenosis.  All other causes, such as cancer, account for less than 1% of cases (Deyo 2001).  During the COVID-19 crisis, there are many individuals who have become sedentary during the stay-at-home orders, contributing to the deconditioning.

Early intervention and recovery from acute low back injury (defined as < 1 month) by training the deep spinal muscles can take only 2-3 weeks (Hides 1996), whereas recovery from chronic low back pain (defined as >3 months) by training the deep spinal muscles can take 6-10 weeks. (O’Sullivan 1997).

There is evidence that manual ‘hands-on’ therapy treatment methods used by physical therapists and chiropractors can be effective for the relief of pain and restoration of motion in the short term (Anderson 1992), but these treatment methods have not met the challenge of lessening persistent and recurrent episodes of low back pain (Richardson 1999).  As a component of musculoskeletal physical therapy, the spinal stabilization program (specific low back exercises) is more effective than manually applied therapy in treating chronic low back disorder over time (Goldby 2006).

Further, research has identified that with acute first-episode low back pain and subsequent untreated chronic low back pain the deep stabilizing muscles of the spine are immediately inhibited leading to a cascade of inefficient spinal structure compensations (Hides 1996, Hodges 1996).  Introducing an active exercise program that specifically reactivates and trains these important supporting muscles of the spine is critical for the return of function and reduction in pain (Jull 2000).

During a study, participants were separated into two groups depending on the types of interventions received.  One group intervention consisted of exercises aimed at rehabilitating the spinal stabilizing musculature.  The other was “medically managed” which  included advice and use of medications.  At 1 and 3 years post treatment, telephone questionnaires were conducted with patients. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84%.  Two to three years after treatment, specific exercise group recurrence was 35%, and the medical management group recurrence was 75% (Hides 2001).

Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone (Hides 2001).

Empowering the Patient to Become Engaged in Their Own Care

The Guide to Physical Therapist Practice recommends therapists should identify the patient’s goals and objectives during the initial examination in order to maximize outcomes.  The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence to make the best clinical decisions and achieve optimal outcomes. 

Exercise prescriptions for low back pain can be much more effectively and efficiently delivered via web-based telehealth.  Patients can provide more responsive feedback about the exercises as the therapist observes them performing the plan of care in their own environment. Modifications can be made to facilitate progression and achieve more successful outcomes.

Adherence to recommended active evidence-based care is associated with better clinical outcomes and decreased subsequent use of prescription medication, MRI, and injections.  Patients receiving evidence-based care had fewer physical therapy visits with lower charges (a mean difference of $167), and greater improvement in pain and disability (Fritz 2008).  Simply put, using evidence based protocols improves the cost-effectiveness of care for acute LBP.

Communication, monitoring and feedback, education, reminders, evidence- based guidelines, progress tracking, and collaborative goal setting all play a role in patient self-management.  They lead to an engaging, empowering healthcare experience that puts the patient in a position where they can effectively self-manage and achieve more successful, cost-effective low back pain outcomes.  In this era of the Covid-19 pandemic, this collective treatment approach is even more important now given the increased prevalence of Low Back Pain and the changes in how rehab therapy is administered. 

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