Struggle with back pain? Pitt is testing a new way to fight it
March 17, 2015 12:00 AM
Dance instructor Chris Roth, owner of Steel City Ballroom in Mt. Lebanon, works on a salsa dance with student Becky Stern. Mr. Roth was part of the University of Pittsburgh $14 million to study better ways to prevent lower back pain.
By David Templeton / Pittsburgh Post-Gazette
After he’d 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 Mr. Roth. As owner of Steel City Ballroom in Mt. Lebanon, he teaches the trademark hip-shaking and body-twisting steps of ballroom dancing. “I canceled my lessons,” said the 44-year-old Bethel Park resident. “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 Mr. Roth, Anthony Delitto was a student. The chairman of the the University of Pittsburgh department of physical therapy in the School of Health and Rehabilitation Sciences offered to help.
In his office, Mr. Delitto analyzed Mr. 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 Mr. 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.
Mr. 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,” Mr. 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 Pitt-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 convince the patient to continue doing everyday activities.
Called “Target,” the project will recruit 60 primary-care clinics affiliated with the five medical centers including UPMC. Each randomly will be assigned to follow one of the two protocols.
Mr. Delitto said the trial will include 2,640 patients with acute lower back pain, with each experiencing pain less than half the time and for fewer 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,” Mr. Delitto said. “We think we can improve outcomes in patients, so there is less a tendency of chronic lower back pain.
“For the vast majority of people, there is not an identifiable cause. It is elusive,” he said.
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 Pitt 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.
The Pitt-led study focuses on steps to prevent the pain from becoming long-lasting.
“Clinicians need this knowledge, and they are taking an approach that will de-emphasize medications and imaging, and emphasize returning the patient to functioning,” Dr. Carey said. “Additional studies similar to this one will be needed. Back pain has a lot of aspects but the Pitt study will surely contribute to our knowledge.”
The latest award reflects Pitt’s success in landing PCORI funding through its Comparative Effectiveness Research Center, which now has received 14 PCORI research awards.
Generally, PCORI’s goal is to engage patients in a health care team focused on achieving the patient’s treatment goals. For example, doctors may recommend a new treatment to extend life a few months, but the patient might decide, instead, to maximize quality of life.
”We built the necessary methodological expertise and data environment to allow researchers to answer the questions facing our health system that are important to patients,“ said Sally C. Morton, the Pitt research center director.
Improving medical practices and outcomes while advancing national policy to reduce health care costs is PCORI’s goal. Lower back pain is a good example.
“We want to do something about lower back pain, which bothers a lot of people, costs us a lot of money, prevents people from enjoying their family lives and going to work,” she said.
David Templeton: email@example.com or 412-263-1578.
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