After he had battled lower back pain for three months with hot showers, analgesic heat rubs and heating pads, it finally happened. Chris Roth awoke one morning barely able to move.
This was a huge problem for Roth. As owner of Steel City Ballroom in a Pittsburgh suburb, he teaches the trademark hip-shaking and body-twisting steps of ballroom dancing. “I canceled my lessons,” said Roth, 44. “I’d had back pain but not like that. This was the most extreme pain. That’s when I couldn’t push through it.”
Fortunately for Roth, Anthony Delitto was a student. The chairman of the University of Pittsburgh department of physical therapy in the School of Health and Rehabilitation Sciences offered to help.
In his office, Delitto analyzed Roth’s posture and how he walked to figure out the potential source of his pain. Then he had him lie down on his back and cross his legs in a figure-four position. Then he pounced on him and rocked him back and forth a few times. They heard a pop. The pain vanished. The hip was realigned. Back to the ballroom.
But Roth’s efforts to continue dancing throughout the pain actually represents a new approach to treating lower back pain. Don’t shut down. Remain active. Push through the pain so it doesn’t become chronic.
To study that concept, Patient-Centered Outcomes Research Institute has awarded the University of Pittsburgh $14 million over five years to lead a national trial to test whether a more aggressive European treatment can better prevent acute lower back pain from becoming a chronic condition in which the level of pain magnifies and is more difficult and expensive to treat.
Participants in the trial include Intermountain Healthcare in Salt Lake City, Johns Hopkins Hospital and Health System in Baltimore, the Boston Medical Center and the Medical University of South Carolina.
Delitto will lead the trial to test the European treatment against “usual care” in which the doctor decides on treatment.
“Certain patients are more inclined to worry that when their back hurts they are further harming it, causing them to become inactive,” he said. “That can seriously impede recovery and cause further damage, leading to chronic back pain.”
Lower back pain, especially with no signs of a fracture or muscle damage, makes it imperative that the person stay active, in shape and on the job. “Chronic lower back pain is clearly something we would like to avoid,” Delitto said.
Intense lower back pain can stab like a knife when a person picks up a dropped pencil or lifts a child. Or it could be the swing of a golf club or a slip on the ice.
But once it occurs, acute lower back pain can flash periodically throughout the day and continue for weeks, months and even longer. If it extends beyond six months, the pain could become chronic. About 10 percent of those experiencing lower back pain end up with a chronic condition.
The annual health care cost of lower back pain in the United States is $86 billion, a Journal of the American Medical Association study reports, making it one of the costliest conditions in American medicine.
The Patient-Centered Outcomes Research Institute is a nonprofit, nongovernmental organization created through the Affordable Care Act of 2010. Its mandate is to improve health care by helping patients, caregivers, clinicians, employers, insurers and policy makers make more informed health decisions. It funds projects that compare the costs and effectiveness of treatment options.
In that context, the Pittburgh-based trial will compare the “usual care” approach against the European strategy, which involves a primary care physician and a physical therapist. Cognitive behavior therapy can help the patient put back pain in perspective and persuade the patient to continue doing everyday activities.
Called “Target,” the project will recruit 60 primary care clinics affiliated with the five medical centers including University of Pittsburgh Medical Center. Each randomly will be assigned to follow one of the two protocols.
Delitto said the trial will include 2,640 patients with acute lower back pain experienced less than half the time and for less than six months. Researchers will evaluate them based on their response to pain and their predisposition to avoiding pain out of fear of further injury. The team also will document the number of X-rays, surgeries and other related medical procedures each patient has experienced.
A World Health Organization report on lower back pain says risk factors include “occupational posture, depressive moods, obesity, body height and age,” while noting that its causes and onsets “remain obscure and diagnosis difficult to make.”
“Back pain is not a disease but a constellation of symptoms. In most cases, the origins remain unknown,” the report says.
“What’s good for the heart is good for the back. You have to be active and engaging in life. Walking and exercise are important to health,” Delitto said. “We think we can improve outcomes in patients, so there is less a tendency of chronic lower back pain.”
Timothy Carey, director of the Cecil G. Sheps Center for Health Services Research at University of North Carolina Chapel Hill, has conducted several back pain studies over the past 25 years. He said he’s familiar with the Pittsburgh project.
“Chronic back pain is tremendously disabling, with high costs in terms of medical expenses and time off work, as well as the burden of chronic pain and reduced function by patients,” he said.
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