Finally, Some Good News About Back Pain

Back pain is a huge problem in developed nations worldwide. It has or will affect most of us. The current estimate is that 80% of people will experience back pain at least once. It is the single biggest cause for disability, the third most common reason for doctor visits, and one of the most common reasons for missing work.

It's also expensive. Back and neck pain makes up the biggest healthcare expense in the US, totaling $134 billion spent in 2016. The next two most expensive conditions were diabetes — $111 billion in spending — and ischemic heart disease at $89 billion.

Diabetes and heart disease being so expensive to treat doesn't surprise most folks - they can both lead to other major problems, require long term medication, could require surgery, and both can be fatal. Back pain won't kill you, usually doesn't require long term medication, and usually doesn't require surgery either. Why is it so expensive?

The first reason is that it's so common. The second reason is that our current system isn't very good at treating it. Current recommendations include starting with activity modification, and active treatments like physical therapy. Research backs this up, showing better outcomes and lower costs with early PT. Unfortunately, only 2% of people with back pain start with PT, and only 7% get to PT within 90 days. At the same time, a study looking at about 2.5 million people with back pain in JAMA showed that 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. Both of these things go against current practice guidelines for treatment of back pain.

A new pilot program being rolled out by TRICARE, the insurance system used throughout the US military is waiving the payment owed by the patient for up to three PT sessions in an attempt to improve the use of what the Defense Health Agency calls "high value" treatment for low back pain. The theory is that once a person sees some benefit from PT treatment, they're likely to go back for more. This is the "try it before you buy it" approach - think of the 7-day free trial Netflix offers, free samples poured in wineries and craft breweries, or the folks you see standing around in supermarkets with food on toothpicks. TRICARE's data seems to indicate that it works just as well for healthcare as it does for other businesses. In a press release they state that once people attend one session of physical therapy, they're likely to go back for more, no matter what their co-pay is. But TRICARE found that higher co-pays could be a barrier to people trying that first visit. For the group of patients with the highest co-pays in the system, only 38% of the people prescribed PT attended the first visit. That's about half the rate of attendance found in the lowest co-pay group.

The fact that such a major insurer is looking into the value of PT is great news for everyone. If TRICARE can show that lowering the cost of PT for patients can improve outcomes and save insurance companies money, other major insurers will likely follow. This could improve the lives of millions of people every year while reducing the huge cost of treating low back pain for the country. That seems like a win for everyone involved.


-- American Physical Therapy Association

In Person or Virtual PT? Maybe Both!



Virtual physical therapy has quickly moved from a niche offering to the mainstream. Having more options is great, but it can also complicate decision making. Having an understanding of the benefits of both can help make clear which one would best help you meet your goals.

In Person Physical Therapy
The main advantage of traditional "brick and mortar" PT is that the therapist is in the room with you. That means they can move around to see how you're moving from different angles, physically adjust your position or movement as you exercise, and physically examine you - testing your strength, measuring your range of motion, etc. They can also use things like manual therapy, electrical stimulation or ultrasound when you're in the clinic. In person PT may work best for:
● New patients - the ability to physically examine you makes it easier for your PT to accurately diagnose what's going on
● Less active patients - if you're not used to exercising and moving, having someone physically present to coach you along can be a big benefit
● People with complicated or chronic conditions - if your back has been hurting for the last 5 years and you've been ignoring it, providing a diagnosis and treating it totally virtually will be difficult for your PT
● Less motivated patients - virtual PT requires you to do most of your exercises by yourself. If you need someone watching over you to make sure you do them, in person PT might work better for you

Virtual PT
The main benefit of virtual PT is convenience. Because virtual PT relies on you doing most of your exercise and treatment on your own, appointments can be shorter. This also means that motivation is a prerequisite to choosing virtual PT. The fact that you don't have to travel to the clinic makes it easier to squeeze a visit into a busy schedule. Virtual PT works well for:
● Athletes and others with good body awareness - being on your own for your home exercise program requires you to be in tune with your body and how it's moving
● People with common athletic injuries - things like tendonitis, sprains, strains, plantar fasciitis, and overuse injuries are commonly treated by PTs. Because of that, there is a template for treatment that is easily adapted to individual needs.
● People who are comfortable with technology - you don't have to be a technology whiz, but having some familiarity with skype, facetime, or zoom helps!
● Existing and returning patients - if your physical therapist knows you, it's easier to treat you virtually.


Both options have benefits and limitations. One or the other might be right for you and your needs, but they're not mutually exclusive. Combining the two can work well for many people.

Doing an in person visit for your initial evaluation and perhaps a follow up visit or two will let
your therapist provide an accurate diagnosis and get you started on your exercise program. Once you're comfortable with your exercise program, you can transition to virtual visits.

Finding the Right Pillow

Finding the right pillow to sleep on at night can be a challenge and with all the various options available now the process is overwhelming.  Ultimately the best pillow is going to be one that can support your head and neck in proper alignment with your spine and conforms to your preferred sleep position.  Pillows that are too flat will likely cause your head to be lower than your spine causing too much extension in your neck.  Conversely, pillows that are too thick will cause your neck to be in too much flexion and thus your head is too far forward.  It is important to select a pillow that is made from a material that gives slightly, is comfortable, and can be easily shaped into a proper position or can contour to your body to maintain a neutral head and neck position.  


For side sleepers, it is best to find a pillow that is thick enough to fill the space between your mattress and your ear while keeping your head in neutral alignment.  The pillow should be positioned up against the shoulder you are lying on and should not cause your head to tilt to either side too much.


For back sleepers, it is best to find a pillow that keeps your neck in neutral alignment allowing the nose and chin to be level with one another.  It should also be positioned up against your shoulder to help support the back of the neck.  


The type of material your pillow is made from is also important to consider. Most people find that memory foam, latex, buckwheat or feather pillows provide the best balance of both support and pressure relief.  It is important to replace your pillow when it is no longer providing your head and neck with proper support. 


If you are having cervical, thoracic, and scapular pain and are unsure if your pillow may be contributing to your symptoms, contact our office to schedule an evaluation and let us help you manage your pain and improve your sleep quality. 


For more information regarding pillows check out the Sleep Foundation Website at


Jen Buono, PT, DPT

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