"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Friday, February 11, 2011

Disability Rising Due to Inappropriate Primary Care for Lower Back Pain

Would you go to see an emergency room doctor for treatment of your painful back?

I wouldn't.

Busy emergency room doctors don't want us there either. They are busy saving peoples' lives.

But, this recent report from the Healthcare Cost and Utilization Project at the Agency for Healthcare Research and Quality (AHRQ) indicates that more people are getting treatment for lower back pain in the emergency room than might be warranted.

Hospitalizations doubled from 1993 to 2008 for patients with back problems.

Hospitalized patients with back pain cost $14,338 while patients without back pain cost $9,055. This may be due to the outlier effect of increasing rates of complex, multi-level spinal fusion surgeries that cost $88,000.
"...hospitalizations for back problems in general were more expensive than all other inpatient stays..."
The aggregate costs for inpatient stays principally for back problems was over $9.5 billion in 2008, making it the 9th most expensive condition treated in U.S. hospitals.

Disability Rising

A study from North Carolina followed-up on 5,357 households to calculate the trend in disability due to lower back problems. From 1992 to 2006 chronic, impairing lower back pain rose in North Carolina from 3.9% to 10.2% of the population.

The study authors speculated the causes might be the following:
  • Rising rates of Obesity: the number of obese people in North Carolina has increased from 13.4% to 26.6% of the population. Obesity is defined a Body Mass Index greater than 30.0 (weight in kilograms per height in meters squared).
  • Increases in depression prevalence: rates of depression doubled from 3.3% to 7.06% through 2002. Chronic pain and depression are linked and individuals with depression are 3 times more likely to develop lower back pain.
  • Medicalization of lower back pain: competing healthcare professionals, some advertising on the Internet, have increased public awareness of treatment possibilities despite the fact that many of these treatments are expensive and offer no better long-term improvement than no treatment.
The most at-risk group of North Carolinians are the age group from 45 to 54 years: they became chronically painful at the highest rate of any cohort. Their incidence increased from 15.2% to 26.7% over the time period.

Heavy, Sad and High Tech

According to a recent report in the Journal of the American College of Radiology up to 50% of diagnostic imaging tests are unnecessary and don't add to the patient's improvement.

Imaging scans cost $100 billion annually and these costs are growing 17% per year.

Physician could improve their targeted care of emergent conditions and better serve patient in need by reducing unnecessary imaging for lower back pain.

The following guideline from the American College of Radiology shows a clinical summary of imaging advice.

Further, physicians could reduce the medicalization of common, age-related physical impairments associated with lower back pain by encouraging their patients to exercise and take care of themselves before problems arise.


  1. Tim,

    Excellent and timely post. These are the areas where physicians need better education and execution of the current evidence. Maybe more importantly this is where PT's can play an amazing cost saving and potentially outcomes improving role!!

    One thought. What if ALL Emergency Rooms/Departments had physical therapists? Could they maybe help in the inadequate care that is received by some in ED's in regards to proper management of common musculoskeletal and pain conditions? I think so. Check out my blog post at PT Think Tank regarding a talk about PT's in ED's: http://ptthinktank.com/2011/02/10/physical-therapists-in-the-emergency-department/

    Some of these issues where addressed directly at talks at Combined Sections Meeting in New Orleans this past weekend.

    In addition there was another talk about how to integrate the American College of Radiology Appropriateness for Imaging Guidelines into PT practice. I say take it step further and use those guidelines to educate patients, colleagues, physicians, legislators, and payors. A blog post about that talk: http://ptthinktank.com/2011/02/13/american-college-of-radiology-appropriateness-criteria-for-imaging/

    As always, great information Tim. Keep up the nice work!

  2. I would love working in the ER. I also specialize in acute dizzy patients and I understand a fairly high proportion of dizzy patients present to the ER.

    The challenge is to distinguish BPPV, which responds well to physical therapists' interventions like canalith re-positioning, from more serious emergent strokes.

    I just read about a new (2009) clinical test which is better than diffusion-weighted MRI in distinguishing vestibular dizziness from an emergent stroke within the first 48 hours.

    I think physical therapists could really make an impact in the ER!

    Published in the September 2009 Stroke journal:


    Thanks for your comments, Kyle. I'm glad to hear we're thinking along the same lines.


  3. One of the reasons I have enjoyed running a POPTS since September. Acute LBP patients are immediately referred for PT, sometimes I consult during the office visit with the MD. The patients are free to investigate their options and seek care elsewhere. Some do so, and nobody "get mad", we remain available if they need us. I am routinely called upon to educate patients with musculoskeletal pain problems during office visits. Sometimes it results in a PT referral, and sometimes it results in a simple exercise program prescription and good will generated.


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