Low Back Pain Management: The Case for Conservative Care

A new multidisciplinary collaborative—the Duke Spine Health Program—aims to enhance access to and improve the use of patient-centered, non-pharmacologic options commonly used by chiropractors and physical therapists as frontline treatments for low back and neck pain.

“Duke is committed to ensuring that patients with spine-related disorders receive the best care possible. Unfortunately, many available treatments—including opioids—are frequently associated with more harm than benefit to patients,” says Christine Goertz, DC, PhD, vice chair for implementation of spine health innovations in the Duke Department of Orthopaedic Surgery.

The program brings together chiropractors, physical therapists, acupuncturists, cognitive behavioral therapists, and other Duke clinicians to offer evidence-based conservative care—including spinal manipulation, exercise, massage, acupuncture, tai chi, and yoga—to treat patients with low back pain before considering medication.

Low back pain affects more than 31 million Americans at any given time and is a key source of medical costs and disability. It has many potential underlying causes, including muscle spasms or spinal stenosis, but there remain large gaps in clinical knowledge about why low back pain transitions from acute to chronic. And while many patients are referred to orthopaedic surgeons or neurosurgeons for spine surgery consultation, it is estimated that only a very small percentage of people with low back pain have an underlying condition that can be resolved through surgery, Goertz says.

“Often, patients who receive early conservative care have better outcomes and are less likely to develop chronic low back pain. In fact, the American College of Physicians recommends this approach for nonradicular low back pain before prescribing medication,” she adds. “Ensuring that each patient gets the right care from the right provider at the right time is not just a matter of convenience—it’s critically important to our patients’ long-term outcomes.” 

Goertz and her Duke co-principal investigator Adam Goode DPT, PhD, were recently awarded an NIH grant for $958,353 to assess the capacity of Health Care Systems to move guideline-based care for low back pain to the forefront of the patient experience by rigorously evaluating a multidisciplinary conservative care model that utilizes doctors of chiropractic and physical therapists as the first point of contact for patients with low back pain. The results from this study will directly inform implementation and policy efforts to improve the quality of pain management for patients suffering from low back pain while simultaneously reducing opioid prescriptions, health care costs, and utilization of services.  

In the meantime, the Duke Spine Health Program is focused on providing training and tools for both patients and physicians about best practices for low back pain. These efforts are facilitated through a care redesign project and a low back pain performance measurement registry that is used to collect baseline data and quantify the impact of using conservative care before turning to treatment options that include imaging, injection, medication, or surgery. “What we’re seeing so far is that the majority of patients don’t receive conservative care at Duke before they see a primary care physician or a specialist for their low back pain,” notes Goertz. This is one of the things the Duke Spine Health Program is aiming to change.  

“There are many patients who have been living in debilitating pain for a long time and going from provider to provider to try to find a solution,” Goertz says. “At Duke, we offer a full range of treatment options for low back pain. As a result, we are able to provide patients with a coordinated multi-disciplinary care plan that best addresses their particular situation."

Goertz recommends the following talking points for providers to consider when starting a conversation with patients regarding conservative treatment for low back pain.

• The American College of Physicians recommends non-drug treatments commonly used by chiropractors and physical therapists before trying prescription medications.
• Due to the self-resolving nature of low back pain, the vast majority of patients will get better with appropriate education and time.
• Movement and exercise are a very important part of the healing process, and there are plenty of options for patients to choose from, depending on their situation and preferences.
• Prescription medications are best suited for short-term use to manage moderate to severe breakthrough pain.
• Imaging, surgery, or injections are not recommended until at least a six-week trial of conservative care is carried out. The majority of patients recover during this time period.

“Even if a patient has seen other DCs or DPTs in the past without success, I would encourage them to consider the Duke Spine Health Program,” Goertz adds. “Our providers are specialists in spine care delivery and best practices and may be able to help your patients.”

Click on the links below for additional details about the Duke Spine Health Program:

• Provider information
• Patient fact sheet