The American Physical Therapy Association (APTA) is urging patients with musculoskeletal pain to consider treatment by a physical therapist, in light of a new federal survey showing that more than one-third of American adults and nearly 12 percent of children use alternative medicine – with back and neck pain being the top reasons for treatment.
Results of the 2007 survey of more than 32,000 Americans were released December 11 by the National Institutes of Health’s National Center for Complementary and Alternative Medicine.
According to APTA, physical therapy offers an evidence-based, time-tested solution to these common conditions in comparison to alternative treatments.
For neck pain, for example, a recent study published in the medical journal Spine found that when patients received up to six treatments of manual physical therapy and exercise, they not only experienced pain relief, but were also less likely to seek additional medical care up to one year following treatment.
“This study, demonstrating the efficacy of physical therapy for a condition as widespread as neck pain, is particularly relevant in today’s challenging economic environment,” according to the study’s lead researcher and APTA spokesman Michael Walker, PT, DSc, OCS, CSCS, FAAOMPT. “The Kaiser Foundation, for instance, recently found that more than half of all Americans are not taking prescribed medication and postponing needed medical care in an effort to save money. It is important for consumers to know that there are effective, conservative solutions such as physical therapy available.”
Walker’s study compared the effectiveness of a three-week program of manual physical therapy and exercise to a minimal intervention treatment approach for patients with neck pain.
Study participants consisted of 94 patients with a primary complaint of neck pain, 58 (62%) of whom also had radiating arm pain. Patients randomized to the manual physical therapy and exercise group received joint and soft-tissue mobilizations and manipulations to restore motion and decrease pain, followed by a standard home exercise program of chin tucks, neck strengthening, and range-of-motion exercises. Patients in the minimal intervention group received treatment consistent with the current guidelines of advice, range-of-motion exercise, and any medication use prescribed by their general practitioner. Patients did not have to complete all six visits if their symptoms were fully resolved.
Sample exercises to relieve neck pain can be found on the APTA Web site, http://www.apta.org/consumer.
Results show that manual physical therapy and exercise was significantly more effective in reducing mechanical neck pain and disability and increasing patient-perceived improvements during short- and long-term follow-ups. These results are comparable with previous studies that found manual physical therapy and exercise provided greater treatment effectiveness (Hoving et al, 2002) and cost effectiveness (Kothals-de Bos et al, 2003) than general practitioner care.
1.Hoving et al. Manual Therapy, Physical Therapy, or Continued Care by the General Practitioner for Patients With Neck Pain. Ann Intern Med, 2002;136 DOI: (10):713-722
2.Bos et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial * Commentary: Bootstrapping simplifies appreciation of statistical inferences. BMJ, 2003; 326 (7395): 911 DOI: 10.1136/bmj.326.7395.911
Among adults with chronic low back pain, both mindfulness-based stress reduction and cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations when compared with usual care, according to a study appearing in the March 22/29 issue of JAMA.
Low back pain is a leading cause of disability in the United States. There is need for treatments with demonstrated effectiveness that are low risk and have potential for widespread availability. Mindfulness-based stress reduction (MBSR) focuses on increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions. Only 1 large randomized clinical trial has evaluated MBSR for chronic low back pain, and that trial was limited to older adults.
Daniel C. Cherkin, Ph.D., of Group Health Research Institute, Seattle, and colleagues randomly assigned 342 adults age 20 to 70 years with chronic low back pain to receive MBSR (n = 116), cognitive behavioral therapy (CBT; n = 113), or usual care (n = 113). CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever other treatment, if any, the participants received. The average age of the participants was 49 years; the average duration of back pain was 7.3 years.
The researchers found that at 26 weeks, the percentage of participants with clinically meaningful improvement on a measure of functional limitations was higher for those who received MBSR (61 percent) and CBT (58 percent) than for usual care (44 percent). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 44 percent in the MBSR group and 45 percent in the CBT group, vs 27 percent in the usual care group. Findings for MBSR persisted with little change at 52 weeks for both primary outcomes.
“The effects were moderate in size, which has been typical of evidence-based treatments recommended for chronic low back pain. These benefits are remarkable given that only 51 percent of those randomized to receive MBSR and 57 percent of those randomized to receive CBT attended at least 6 of the 8 sessions,” the authors write.
“These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain.”
Editorial: Is It Time to Make Mind-Body Approaches Available for Chronic Low Back Pain?
“Although understanding the specificity of treatment effects, mechanisms of action, and role of mediators are important issues for researchers, they are merely academic for many clinicians and their patients. For patients with chronic painful conditions, options are needed to help them live with less pain and disability now,” write Madhav Goyal, M.D., M.P.H., and Jennifer A. Haythornthwaite, Ph.D., of Johns Hopkins University School of Medicine, Baltimore.
“The challenge is how to ensure that these mind-body interventions are available, given the existing evidence demonstrating they may work for some patients with chronic low back pain. Most physicians encounter numerous obstacles finding appropriate referrals for mind-body therapies that their patients can access and afford. High-quality studies such as the clinical trial by Cherkin et al create a compelling argument for ensuring that an evidence-based health care system should provide access to affordable mind-body therapies.”
1.Daniel C. Cherkin, Karen J. Sherman, Benjamin H. Balderson, Andrea J. Cook, Melissa L. Anderson, Rene J. Hawkes, Kelly E. Hansen, Judith A. Turner. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA, 2016; 315 (12): 1240 DOI: 10.1001/jama.2016.2323
2.Madhav Goyal, Jennifer A. Haythornthwaite. Is It Time to Make Mind-Body Approaches Available for Chronic Low Back Pain? JAMA, 2016; 315 (12): 1236 DOI: 10.1001/jama.2016.2437
An estimated 126.6 million Americans (one in two adults) are affected by a musculoskeletal condition–comparable to the total percentage of Americans living with a chronic lung or heart condition–costing an estimated $213 billion in annual treatment, care and lost wages, according to a new report issued today by the United States Bone and Joint Initiative (USBJI).
Musculoskeletal disorders–conditions and injuries affecting the bones, joints and muscles–can be painful and debilitating, affecting daily quality of life, activity and productivity. “The Impact of Musculoskeletal Disorders on Americans: Opportunities for Action” outlines the prevalence and projected growth of musculoskeletal disorders in the U.S., and recommends strategies for improving patient outcomes while decreasing rising health and societal costs.
“This report provides the critical data needed to understand the magnitude of the problem, and the burden, of musculoskeletal disease in our country,” said David Pisetsky, MD, USBJI president, and professor of medicine and immunology at Duke University Medical School. “The number of visits to physicians for these disorders, the cost of treating them, and the indirect costs associated with pain and loss of mobility, are proportionately much higher than the resources currently being allocated to combat these conditions and injuries.”
“As a nation, we need to establish greater funding for musculoskeletal research, improve our understanding and strategies for prevention and treatment of these injuries and conditions, and ensure that more adults and children receive appropriate treatment sooner, and on an ongoing basis, to ensure quality of life and productivity,” said Stuart L. Weinstein, MD, co-chair of the report’s Steering Committee and a professor of orthopaedics and rehabilitation at the University of Iowa Hospitals and Clinics.
Prevalence and predictions
According to the report, the most prevalent musculoskeletal disorders are arthritis and related conditions; back and neck pain; injuries from falls, work, military service and sports; and osteoporosis, a loss of bone density increasing fracture risk, primarily in older women. An estimated 126.6 million Americans were living with a musculoskeletal disorder in 2012. More specifically:
•Arthritis is the most common cause of disability, with 51.8 million–half of U.S. adults age 65 and older–suffering from the disease.
•With the aging of the American population, the report projects arthritis prevalence to increase to 67 million people, or 25 percent of the adult population, by 2030.
•Arthritis is not just a disease for older Americans, with two-thirds of arthritis sufferers under age 65.
•Back and neck pain affects nearly one in three, or 75.7 million adults.
•Osteoporosis affects 10 million Americans, with 19 million more (mostly women) at risk for the disease.
•One in two women and one in four men over the age of 50 will have an osteoporosis-related fracture, and 20 percent of hip fracture patients over age 50 will die within one year of their injury.
Cost and health care impact
The burden of musculoskeletal conditions is significant in terms of treatment and care, as well as the impact upon of quality of life, mobility, and productivity, and resulting in fewer days at work and in school. In 2011, the annual U.S. cost for treatment and lost wages related to musculoskeletal disorders was $213 billion, or 1.4 percent of the country’s gross domestic product (GDP). When adding the burden of other conditions affecting persons with musculoskeletal conditions such as diabetes, heart disease and obesity, the total indirect and direct costs rose to $874 billion, or 5.7 percent of the GDP in 2015.
Other data on the costs of musculoskeletal diseases and injuries include:
•Eighteen percent of all health care visits in 2010 were related to musculoskeletal conditions, including 52 million visits for low back pain, and 66 million for bone and joint injuries, including 14 million visits for childhood injuries.
•Arthritis and rheumatoid conditions resulted in an estimated 6.7 million annual hospitalizations.
•The average annual cost per person for treatment of a musculoskeletal condition is $7,800.
•The estimated annual cost for medical care to treat all forms of arthritis and joint pain was $580.9 billion, which represented a 131 percent increase (in 2011 dollars) over 2000.
•In 2012, 25.5 million people lost an average of 11.4 days of work due to back or neck pain, for a total of 290.8 million lost workdays in 2012 alone.
•Among children and adolescents, musculoskeletal conditions are surpassed only by respiratory infections as a cause of missed school days.
Opportunities for action
The report provides recommendations to curb the tremendous economic and societal costs of musculoskeletal disorders, including:
•Accelerating research that compares treatment alternatives, develops new treatments and evaluates possible preventative approaches.
•Improving understanding of the role of behavior change in prevention and treatment, including weight loss and self-management of conditions once they arise.
•Ensuring that a higher percentage of the affected population receives access to evidence-based treatments.
•Implementing proven prevention strategies for sports injuries, workplace injuries, and injuries in the military.
•Ensuring that all children with chronic medical and musculoskeletal problems have access to care.
•Promoting better coordination between physicians and other health care providers treating musculoskeletal disorders: primary care physicians, specialists, physical therapists, etc.
•Ensuring that health care providers, especially primary care physicians, have the appropriate training to diagnose, and if necessary, refer patients for appropriate treatment.
•Addressing data limitations, and improve systems, to improve our understanding of these conditions and how best to screen, diagnose and treat them. This includes the impact of sex and gender on musculoskeletal disorders and responses to treatment, and tracking pediatric patients through adulthood to determine the lifelong burden of musculoskeletal disease.
“If we continue on our current trajectory, we are choosing to accept more prevalence and incidence of these disorders, spiraling costs, restricted access to needed services, and less success in alleviating pain and suffering — a high cost,” said Edward H. Yelin, PhD, co-chair of the report’s steering committee, and professor of medicine and health policy at the University of California, San Francisco. “The time to act to change this scenario to one with more evidence-based interventions and effective treatments, while simultaneously focusing on prevention, doing better by our society and economy, is now.”
American Academy of Orthopaedic Surgeons. “One in two Americans have a musculoskeletal condition: New report outlines the prevalence, scope, cost and projected growth of musculoskeletal disorders in the U.S..”
Golfers with low-back pain may be helped by a University of Pittsburgh research study, the findings of which may assist clinicians in designing appropriate back-specific exercise programs for golfers to prevent or rehabilitate low-back injury.
The findings are being shown today with a poster presentation at the annual meeting of the American Orthopaedic Society for Sports Medicine,July 14-17, at the Keystone Resort in Keystone, Colo.
“More than 30 percent of golfers have experienced issues related to low-back pain or injury that have affected their ability to continue enjoying the game of golf,” said principal investigator Yung-Shen Tsai, Ph.D., P.T., of the University of Pittsburgh Neuromuscular Research Laboratory (NMRL), where the study was conducted.
“Modified swing patterns and general exercises have been suggested for golfers with back problems. However, it is difficult to design an appropriate back-specific swing or exercise program for low-back injury prevention and rehabilitation without knowing the differences in the kinematics and spinal loads of the golf swing and the physical characteristics of golfers with low-back pain,” Dr. Tsai explained.
So, Dr. Tsai’s team set out to examine the kinematics of the trunk and spinal loads in golfers with and without low-back pain (LBP)and their trunk and hip physical characteristics. Sixteen male golfers with a history of LBP were matched by age and handicap to 16 male golfers with no history of LBP. All study participants underwent a biomechanical swing analysis and physical characteristics assessment.The researchers used a 3D motion analysis system and two force plates to assess kinematics and spinal loads of the trunk. They used a bottom-up inverse dynamics procedure to calculate spinal loads of the lower back. In addition, they measured trunk and hip strength and flexibility, back proprioception and postural stability.
“We found deficits in physical characteristics in the golfers with a history of LBP compared to the non-LBP group,” reported Dr.Tsai. “These differences may hinder dissipation of the tremendous spinal forces and movements generated by the golf swing over time and limit trunk rotation during the backswing. These conditions may lead to lower back muscle strain, ligament sprain or disc degeneration.
“Although differences found in this study cannot be determined as causes or results of low-back injuries in golfers, clinicians may be able to use our data to design appropriate back-specific exercise programs for golfers to prevent or rehabilitate low-back injury,” said Dr. Tsai.
Specifically, the LBP golfers in Dr. Tsai’s study demonstrated less trunk and hip strength and less hamstring and right torso rotation flexibility. The LBP group also demonstrated back proprioception deficits significantly in trunk flexion. No significant differences were found for postural stability. The LBP group showed less maximum angular displacement between shoulders and hips during the backswing.No significant differences were found in other trunk kinematics and spinal loads during the golf swing.
Other investigators for this study were: Timothy Sell, Ph.D.,P.T.; James Smoliga, D.V.M; Joseph Myers, Ph.D., A.T.C.; Jean McCrory,Ph.D.; Richard Erhard, D.C., P.T.; and Scott Lephart, Ph.D., A.T.C.
University of Pittsburgh Medical Center. “Golfers With Low-back Pain May Be Helped By University Of Pittsburgh Research.” ScienceDaily. ScienceDaily, 18 August 2005. <www.sciencedaily.com/releases/2005/08/050814174459.htm