Low back pain treatment: are we getting better or worse?

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it's your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. Today I asked ChatGBT in the U.S. over the past 10 years, have we been getting better or worse at managing lower back pain from a private practice perspective? I asked you to give me a little bit of research and data to support the answers. And the reason why I asked it this today was because I had been hearing over and over again from colleagues of mine that we as an industry are getting worse at our outcomes with lower back pain.

Personally, I find that very hard to believe because I think there's great information out there about effective management and all the aspects associated to lower back pain. But I also see that there is very archaic treatments out there as well, like ones that I don't think would conform to the updated standards and also making patients fearful about their lower back pain or their condition. There is a physical nature to lower back pain, but also there's a psychological one, a very large one, especially associated to more chronic conditions. And so I'll share with you today what ChatGBT said, and I'll tell you what I've seen, at least from our practice.

By the way, if you guys do need help, we do have telehealth options. We have consultations. We're licensed in various different states. You can always reach out to us. Our contact is below. So this says, over the past decade, the management of lower back pain in the U.S. private practice has experienced both advancements and ongoing challenges, while there's been a shift to evidence-based multidisciplinary approaches, barriers such as patient's perception, financial constraints, systematic disparities continue to impact care delivery. So the things that have been improved on over the last few years has been the emphasis on non-pharmaceutical treatments.

So clinical guidelines now prioritize non-pharmaceutical interventions for lower back pain, including physical therapy exercise, manual therapy, and patient education. These approaches are tailored to the individual patient's needs and promoting better outcome. The second thing is integrating mindfulness and cognitive behavior therapy. Mindfulness-based pain management programs have been demonstrated to become very effective in improving pain acceptance and quality of life for chronic pain sufferers and have had benefits in reducing pain intensity and enhancing coping strategies. Number three is adoption of telehealth services.

The expansion of telehealth has increased access to care, allowing remote consultations and follow-ups while telehealth visits me result in fewer immediate prescriptions or tests. They oftentimes lead to necessity in-person follow-ups, ensuring comprehensive care. So I think these three things are all pretty spot on. I have heard more and more information about providers suggesting non-pharmaceuticals. I'm, I know for a fact, physical therapy or exercise for various different types of lower back pain, can work very well. That's what we end up using here for a lot of our patients. We do it in our telehealth sessions and we do it in our physical ones too.

Manual therapy, adjusting, even things like acupuncture can be very helpful for pain management, but it doesn't substitute for building strength, building endurance, building resiliency about the person. And also too, it can't be discounted that challenging person, the person with physical activity, whether it be considered physical therapy or exercise or whatever, some are regressed, some are advanced. But we call it collecting wins here. We, a lot of times people come in mentally defeated thinking that they can't actually do anything or it's going to be damaging on their lower back to try things.

And then we get them to do things like, when's the last time you picked up something over 20 pounds on the ground? Man, it's been super long time. I've been so afraid of it. Can you, you want to try it today? Maybe we can elevate it from a block and how's that feel? It feels really good. You want to do it from the floor now? Yeah, let's try it. And then be surprised how much stress has seemingly been taken from them when they see that they're actually physically able to do things. So using non-pharmaceuticals is a really important starting point and you can reserve pharmaceuticals for people who are not responding.

And it's not in my licensing to be able to suggest pharmaceuticals, but I realize there is a time and a place. There's a time and place for injections and surgeries and so on. But most people do get a lot better if they're being told what to do. You can put your hands on them and educate the person about what realistic expectations are. Now, the second part about managing or coping strategies, I think this is something that is important to talk about, but also I think it's been overkilled for a lot of years. I don't think just educating you about your back pain, that it's from a disc and accepting that you're going to have some pain forever is a good strategy.

You can blend that, though, with other types of management, such as, well, you have a disc injury today. Yeah, it's going to probably suck for probably three weeks or so. And assume over the next three to four months, you're going to have a little bit of tweakiness. It may not be perfect, but you should be back to most of your activities. And by the way, the way you're lifting that object right there is actually probably irritating the disc more than helping it. So let's show you how to deadlift something nominal, like 30 pounds or something you may find around the house. Like your dog is 30 pounds.

Let's just show how you pick up your dog. So showing them that they can do things with an acceptable amount of weight and then coaching them into the activity or the way to navigate that weight and accomplish that task is important. Now, we can call this weight training, we can call it physical therapy or physiotherapy or whatever, and it really comes down to in what context it's done. But it's a deadlift, can be done as a strength protocol, if with the right reps and sets. And that's what you see everybody doing in the gym. It can be done as a means to offload the lower back and make it more of a hip-dominant strategy because it is a hip-dominant lift.

And we can do it even just as a pattern, which would be considered more physio or physical therapy. So, although I think the cognitive behavioral therapy and being mindful is important, I think it can be overkilled. But I do think it's an important thing to talk about with patients about expectations or timelines. And I've seen, there's one person that comes to mind is, it's been like six weeks since they had an original disc injury, and it's a good-sized one. And he is wondering why he's not back to normal yet. Like, but he can lift, he can walk, he can jog, but he's like, ah, I just, my hamstring still feels really tight and my hips stiff.

Yeah, it's been three, six weeks since your original injury. Like, so what do you expect? Like, it takes a little bit of time for the tissue to heal itself. You can't accelerate that process, but you can certainly make it worse. So, in the meantime, yes, except these are the normal parameters you should expect, but also let's get you active again. So, you don't become so fearful of doing activity. And that last part here of the telehealth, I think the telehealth aspect is a huge part because it makes less barriers for people. I have one person that he's super great. Like, he's been in here about three times.

I've seen him probably a total of ten times. And he lives about two hours away, so he can't, doesn't, isn't able to drive in all the time. And I've helped him with a lower body condition, and he's very happy with that. He's physically active, but, you know, stuff comes up. And so, it's been about six months he's been talking or emailing me about, well, I got this shoulder problem. And I said, well, can we just do, like, a telehealth one? And just, I assess you and give you suggestions to do for that. And he's like, I think I should really come in. And as I've noticed with a lot of people who are talking about, like, they discount telehealth, they don't really understand that a skilled eye can actually do a lot of assessment.

A lot of the history and diagnosis comes down to listening to you and asking you questions. So, there's pattern recognition that we can follow. We can test exercises to see if they're acceptable. And come up with a remedy that includes things that you can do without any risk, because we've tested them in the exercises or in the exam. And then things that you should stay away from and establish a treatment plan. A lot of the stretches that people find on YouTube, and you'll find a bunch of video comments referencing this, is they'll say, oh, man, I did this stretch, and I haven't felt any pain in, like, three weeks.

It's been great. It's like, how can we reasonably say that telehealth won't help people if they're actually finding self-help on a video already? And it's not even curated to what they have. They're guessing what they have. And so, I think the telehealth does a few things. Number one, it accelerates the intervention point. A lot of times, people will feel a lot better, a lot faster if you get to their problems sooner. Usually, the first 10 days is a little too quick for a lot of people because there's an inflammatory period. But, like, if it's been three months and you still have the same problem and you're like, hi, I can't drive two hours to go.

It's like, do a telehealth. Like, there's so much that we can do. In fact, our practice, and I'm not saying it's only our practice. Like, there's a lot of – there's a fair amount of practices out there that are very good at telehealth. But it's very foreign to a lot of them, too. We started doing it during COVID, and it accounted, actually, for about 40% of our practice. Like, there was days where we'd be in the office where it seems like it's really dead, but we're all on computers helping people from a distance. And we still have a lot of our clients today who end up reaching out with telehealth, and it's usually a distance issue or an issue with they don't have anyone actually around them.

So, we're in California. Like, there's plenty of cities like Northern California that, like, there's no one really around. Like, their healthcare is not – I don't want to say it's not educated, but, like, they don't specialize in certain things. So, we can help those people, and you may have someone in your area who can help you as well just by getting you the care that you need and finding a specialist. Now, there are some challenges, it appears, that ChatGV talks about. It says, overuse of low-value interventions. Number two is patient perception and financial barriers. Number three is disparities in pain management.

So, I won't go over all these too much because we're all going to run out of time, but overuse of low-value interventions. This is what they say. So, avoiding – despite guideline recommendations, there's a noticeable increase in the amount of advanced imaging, opioid prescription for lower back pain, which is not always best aligned with best practices. This is according to the NCBI, and this is a study which is called Worsening Trends in Management and Treatment of Back Pain. This was – what year was this? I'll pull this one up here. This was from – this was from 2013. So, it's a little bit older, but it does take about 10 years, really, for things to get in through research.

But they said the trend it raised is concerning about potential unnecessary procedures and associated risks. So, I would agree with that. I think a lot of times people do have too many images, and they – I haven't met a lot of people with too much opioid prescription, but I know it is out there. And I know that if I was managed poorly for my pain, I wouldn't – I mean, I would do anything to get out of pain. So, I totally understand how people are on opioids or over-the-counter pain medications because it sucks to hurt. You can't sleep. You can't think. And that is the value of doing something like a telehealth or something that's with a skilled provider who has a lot of experience in your problem and can accelerate your recovery timeline.

Most people will find resolution to their problems on their own. Some won't. But working with a skilled provider accelerates that timeline. It's literally a cheat code. And so, the faster you can do it, the better you'll be off mentally. Number two is patient perceptions and financial barriers. Patients often perceive physicians as more authoritative than physical therapists, influencing their treatment choices. Additionally, out-of-pocket costs for therapies like physical therapy, acupuncture, chiropractic care, can deter patients from pursuing these options. This is an article. This is Frontiersin.org.

I'm not sure of the reference of this one. This was from 2021. Multidisciplinary firms and treatment of chronic pain, a case study of lower back pains. This is only a case study. This isn't very big. But I would say that I wouldn't, I wouldn't, I'm not going to go off of this one necessarily, but I would say patient perceptions more of what the treatment, the appropriate treatment is, is a little bit skewed. So, I found a lot of patients, it's actually easier to not combat people. Like, if someone thinks that they want one type of dog and you say, well, I think this dog is better for you. It's a big discussion and it's harder.

And we don't know who is actually right in that scenario. But when it comes to treatment options, it comes down to trialing the treatments. And if one type of treatment is not really succeeding over the course of months and months, maybe we should change courses. But a lot of times people believe certain treatments will help them more than others. And that will skew their judgment a little bit to trying options that may be more appropriate associated to the exam that the provider does. And the trail of evidence that the provider gathers in the history too. So, and I've met many people who want one thing done.

I'm not going to bash on chiropractic adjusting. It definitely holds value. I'm a chiropractor by degree. But we've had so many phone calls where people say, hey, can I just get a quick adjustment? Well, for what? Well, my back, it works. I've been doing it for the past 10 years. It's like, well, is it really working if you need it every couple weeks? You know, so it kind of begs the question of, should I, like, as a business owner, if this does not hurt the person to do the adjustment, you can just do it. That's clearly what they're asking for. It's like, paint my house. Well, okay. Sure. Like, you're giving them what they ask for.

So, it's easier as a business. And that could possibly be part of the reason why some treatments don't necessarily go well. Again, I'm not bashing on the chiropractic adjustment. This happens with stretching. I mean, acupuncture, medication, surgeries. I mean, I've met people who said they begged their surgeon to have surgery. And they said the surgeon's like, absolutely, I will not do this surgery for you. This is not needed. You know, and so there's the person will continue to ask because they believe that's what's appropriate. And it's not always appropriate. So, it's really up to the doctor, the physical therapist, the chiropractor's discretion about what is appropriate and not.

And it's their job to tell that information to you and say, look, I don't think this will hurt you to do, but I don't believe it will really help you either. It is your body you get to choose, but I feel like this type of treatment on the other side here is actually more appropriate for your actual problem. And that's, I think, how we're going to break down that barrier. But I think the overlying theme here is that there are good signs that we're going in the right direction. Non-pharmaceutical treatment should always be considered first, if at all possible. You should always be physically examined, ideally in person.

But if you don't have the amenities around, you don't have anyone skilled in that specialty of the problem that you have, then you should consider telehealth. Telehealth is an excellent choice for accelerating the process and at least getting a head start in the right direction. Now, if you guys are looking for help, again, it just turns out I didn't actually have the telehealth thing on this list. It just came up on its own. But as you listen to some of the other podcasts, you know that we do telehealth. So, if you guys are looking for help with telehealth or in person, just reach out to us. We'd be happy to help.

And also, we have a free webinar for lower back pain in the description for the podcast. Me and Dawne Costantino put this together a few years back. And I think it's a very good webinar. It's a long video. It's basically 20 minutes. And it covers the three most common types of lower back pain. And I think it'll give you some good insight of the way things can be managed. And we try to be very precise with our words. So, making sure that you guys don't feel defeated. You have some idea of what to talk to your healthcare provider about. And then timelines of recovery process. So, I will see you guys next time.

Thanks for listening.