March 17, 2018

Ruth Estrich: Back Pain – Are We Doing More Harm Than Good?

By Ruth Estrich, Chief Strategy Officer, MedRisk

Ruth EstrichAccording to the National Institute of Health, back injuries are the most prevalent occupational injury in the United States. Most Americans will suffer from back pain at some time in their careers, causing them to miss work. According to the U.S. Bureau of Labor and Statistics, productivity losses due to lower back pain are closing in on $30 billion a year. In fact, lower back pain is the leading cause of disability in the working population under the age of 45 and ranks as the number two reason why people see a doctor – second only to the common cold.

Lower back pain is not always the result of an external trauma or injury. The anatomy of the spine is such that it begins to lose water content in our early 30s, increasing the risk of bulges, herniations and even annular tears. These degenerative changes impact almost everyone – whether or not they are actually experiencing symptoms. For example, studies show that disk degeneration exists in 37% of all asymptomatic 20 year-olds, in 80% of all asymptomatic 50 year-olds and in 96% of all asymptomatic 80 year olds.

As lower back pain is clearly the most costly and most prevalent occupational health condition in the United States, it is in everyone’s best interest that the appropriate diagnosis and treatment for the problem be identified and widely implemented. Spine surgery has long been identified as a key cost driver in the management of lower back injuries. In recent years, it has become clearer that there is little to no evidence that these surgeries indeed improve outcomes. These surgeries do however greatly increase the cost of care and the amount of time injured workers are unable to perform their jobs.

A recent study showed that on average, total mean costs for those who have back surgery are roughly double the costs of those who do not. Additionally, 58% of the surgically treated patients miss work as compared to only 36% of the non-operatively treated, and they are off work for longer periods of time – all without any evidence that outcomes are improved for those who undergo surgery. In fact, numerous studies conducted in numerous countries and settings show that patients with lower back pain improve over time, with or without surgical intervention.

Given the risk of surgical complications and the fact that cost and lost time are significantly lower for non-surgically treated patients, one would think surgical rates would be decreasing, when in fact they are not. Spine surgeries have been steadily increasing since the 1990s.

What can be done to decrease the rate of spine surgery? It seems that the most critical predictor of whether injured workers receive spine surgery is the type of practitioner they access. A seminal study by the Washington State Workers’ Compensation Department showed “a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.” After controlling for severity and other issues, workers who first saw a surgeon for treatment had close to nine times the odds of having surgery as did injured workers who first saw their primary care physician for treatment.

Taking this treatment path one step further, a recent study published in Health Services Research showed that when primary care providers referred their patients with uncomplicated low back pain to a physical therapist within the first six weeks, both the short-term and long-term costs associated with the treatment were significantly reduced. Initial costs were 62% lower and costs over the following year were almost 72% lower.

One of the benefits of a physical therapy centric approach to back pain that it provides the patient with tools to address both current and future management of his or her situation – moving the locus of control to self-help and limiting the motivation to seek additional and often unnecessary care. Many studies have demonstrated that the effective use of physical therapy and home exercise is often a cost-effective alternative to both medication and surgery. And while the use of advanced imaging is important to effectively diagnose complicated situations, studies have shown that the use of magnetic resonance imaging for lower back pain in and of itself can lead to the medicalization of the normal changes within the spine of an aging population. Additionally, the well-trained physical therapist can readily determine when progress is not consistent with evidence-based norms, and can provide the treating physician with critical and timely additional information to inform subsequent treatment choices including additional diagnostic testing and the use of opioids and injections, and the identification of psychosocial barriers to recovery.

About Ruth Estrich
Ruth Estrich is Chief Strategy Officer and is responsible for managed care product development as well as vendor partnerships, provider relations and new market penetration. A dynamic industry expert, Ms. Estrich is an active participant in the insurance field. With extensive experience in the property & casualty, group health, and managed care arenas, Ms. Estrich’s product development and management skills are vital to MedRisk’s continued delivery of innovative industry solutions. Ms. Estrich holds a Bachelor of Arts degree from Simmons College in Boston.

About MedRisk
MedRiskMedRisk is the leader in physical rehabilitation and diagnostic imaging solutions for the workers’ compensation industry. Founded in 1994 and based in King of Prussia, Pa., MedRisk is accredited under URAC for utilization management and has successfully completed a SSAE 16 Type II examination. MedRisk’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, and case management companies. To make a referral or obtain more information, visit or call 800-225-9675.

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