Many Alternative Therapies for Back Pain Not Covered

By Pat Anson, PNN Editor

A new study by the Johns Hopkins Bloomberg School of Public Health has confirmed what many back pain sufferers already know: Public and private health insurance plans often do not cover non-drug alternative pain therapies.

Bloomberg researchers looked at dozens of Medicaid, Medicare and commercial insurance coverage policies for chronic lower back pain and found that while most plans covered physical therapy and chiropractic care, there was little or no coverage for acupuncture, massage or counseling.

"This study reveals an important opportunity for insurers to broaden and standardize their coverage of non-drug pain treatments to encourage their use as safer alternatives to opioids," says senior author Caleb Alexander, MD, a professor of epidemiology at the Bloomberg School.  

Alexander and his colleagues examined 15 Medicaid, 15 Medicare Advantage and 15 major commercial insurer plans that were available in 16 states in 2017.

Most payers covered physical therapy (98%), occupational therapy (96%), and chiropractic care (89%), but coverage was inconsistent for many of the other therapies.

Acupuncture was covered by only five of the 45 insurance plans and only one plan covered therapeutic massage.

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Nine of the Medicaid plans covered steroid injections, but only three covered psychological counseling.

"We were perplexed by the absence of coverage language on psychological interventions," Alexander says. "It's hard to imagine that insurers wouldn't cover that."  

Even for physical therapy, a well-established method for relieving lower back pain, insurance coverage was inconsistent.

"Some plans covered two visits, some six, some 12; some allowed you to refer yourself for treatment, while others required referral by a doctor," Alexander says. "That variation indicates a lack of consensus among insurers regarding what model coverage should be, or a lack of willingness to pay for it.”  

The Bloomberg study is being published online in the journal JAMA Network Open.  It was funded by the U.S. Department of Health and Human Services, National Institutes of Health and the Centers for Disease Control and Prevention.  

Lower back pain is the world’s leading cause of disability, but there is surprisingly little consensus on the best way to treat it. A recent series of reviews by an international team of experts in The Lancet medical journal found that low back pain is usually treated with bad advice, inappropriate tests, risky surgeries and painkillers.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” said lead author Rachelle Buchbinder, PhD, a professor at Monash University in Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

The authors recommend counseling, exercise and cognitive behavioral therapy as first-line treatments for short-term low back pain, followed by spinal manipulation, massage, acupuncture, meditation and yoga as second line treatments. They found limited evidence to support the use of opioids for low back pain, and epidural steroid injections and acetaminophen (paracetamol) are not recommended at all.

5 DIY Tips to Reduce Lower Back Pain

By Mark El-Hayek, Guest Columnist

Lower back pain is the world's leading cause of disability. Almost all of us will at some point in our lives have to deal with it.

Lower back pain is any form of pain or discomfort in the lower part of the spine, which is known as the lumbar spine. It can be brought about by things like muscle tension, stress, improper diet, lack of exercise, poor posture, excess body weight and pregnancy.

We put together five simple do-it-yourself tips to help reduce lower back pain.

1) Correct Posture

Poor posture is one of the leading causes of lower back pain. Good posture involves sitting, walking, standing and sleeping in ways that do not weaken or over activate your supporting muscles. There are several things you can do to improve posture.

When sitting, avoid sitting on the edge of a chair as this puts a lot of strain on your back. Sit with your back straight and shoulders back.

The same is true for walking. Avoid bending or slouching over while walking. This strains your back and causes lower back pain.

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When lying down, get into a position that is comfortable and one that does not compromise the curve in your back.

2) Ice and Heat

For many people, putting ice or something cold on an injured area provides relief from pain. Heat also works well in reducing lower back pain, but the two techniques work very differently.

When you put something cold on your lower back, the cold makes the blood vessels constrict, which reduces the pain caused by inflammation. Heat, on the other hand, relaxes blood vessels and increases blood flow, which helps heal the affected area.

It is advisable that when using ice and heat together, you start by doing the cold compress first and then the hot compress. You can use ice packs or frozen peas for the cold compress. For the hot compress, you can use a hot water bottle or a towel soaked in warm water.

Alternate between the cold and hot compresses for a few minutes and you will notice that your lower back pain has reduced.

3) Exercise

Regular exercise is a good way to prevent lower back pain. Make a point of exercising as often as you can. If you have a job that has you sitting for long hours, integrate exercises and movement into your everyday routine.

Walk to the bathroom or the water cooler a couple of times a day to keep your joints moving and lower back pain at bay. Take the stairs instead of the elevator or escalator to help stay fit.

4) Rest

Lower back pain is often caused by stress. The moment you start feeling back pain, take a couple of hours off to rest. You can start by taking a hot shower to help you relax. The shower will help your blood vessels relax and make oxygen flow freely to your lower back. After the hot shower, rest for a couple of hours and you will probably feel better.

5) Do not stay in bed too long

While resting is important, make sure you do not stay in bed too long. Lying down for an extended period of time, especially when your posture is poor or you do not have a good mattress, could increase your lower back pain. Instead of lying down, go for a slow walk to allow your joints and muscles to move and reduce inflammation.

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Mark El-Hayek graduated from Macquarie University in Sydney, Australia with a Masters of Chiropractic and a Bachelor of Medical Science.  He is the head chiropractor and owner of Spine and Posture Care in Sydney.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

The Four C’s That Can Help Lower Pain Levels

By Barby Ingle, Columnist

I hear more than ever from others living with chronic pain that they “have tried everything” and nothing helps. But there are always new pain therapies being developed or improved; some real, some placebo, and some researched more than others. 

I personally don’t believe that there is any one treatment that cures or fixes anyone, but there are many that can help take the edge off the pain we are feeling. I also recognize that some options are not right for some people or contraindicated for certain conditions. There is no one-size-fits-all treatment for chronic pain.

Last month we looked at four alternative therapies that start with the letter “A” (acupressure, acupuncture, aromatherapy and art therapy). This month the spotlight is on four therapies that start with “C” – Calmare, Chinese medicine, chiropractic, and craniosacral therapy. 

Calmare Therapy

Calmare is a relatively new treatment that is becoming more popular. I have tried it myself, and while it was not a long-term useful tool for me, I do know others who have received major benefit and relief from it.

Calmare Therapy, also known as scrambler therapy, is a non-invasive, drug-free solution for neuropathy and other conditions that cause nerve damage. I think of it as TENS unit on steroids. 

Duringtreatment, small electrodes are placed on the skin, which are connected by wires to a box-like device. Electrical pulses are transmitted to the body, like little electric shocks. This can help block pain signals in some people with certain types of chronic pain.

The provider I hear about the most having success with this form of treatment is Dr. Michael Cooney, a chiropractor practicing in New Jersey who sees patients from all over country.

Cooney wrote a guest column about Calmare for PNN a few months ago, where you can learn more about the treatment and how it works.

Chinese Medicine

When people think about Chinese Medicine (CM), many just think of acupuncture, but CM is more than just one modality. It involves a broad range of traditional medicine practices which were developed in China over 2,000 years ago, including various forms of herbal medicine, massage, exercise and dietary therapy.

One of the basic tenets of CM is that the body's vital energy (chi or qi) circulates through channels called meridians, which have branches connected to bodily organs and functions.

CM is being used more and more in American pain treatment as an alternative to Western medical practices. Only six states (Alabama, Kansas, North Dakota, South Dakota, Oklahoma, and Wyoming) do not have legislation regulating the professional practice of CM. 

Be sure to tell all your healthcare providers about any complementary health approaches you use, as it is important to give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care, which is important with more than a million Americans using forms of CM. 

The prices of traditional CM vary, depending on the practitioner and the region. Usually an initial herbal consultation ranges from $30 to $60, and follow-up consultation costs around $30. A month's supply of herbs may cost $30 to $50, but it’s a good value if it helps lower your pain levels, stress and helps regulate your neuro-inflammation.

Chiropractic

Chiropractic care is a harder subject for me. I have had positives and negatives with this treatment and with different practitioners. For the most part, my insurance has covered this type of care, but for many insurance policies it is not covered at all or it only pays for a few appointments a year. 

Chirporactic sessions can range from $34 to $106, depending on where you live, how many areas of the spine the chiropractor services, and whether more extensive exams are required.

This form of alternative care typically treats mechanical disorders of the musculoskeletal system with an emphasis on the spine, although I have had chiropractors adjust my hips, feet and shoulders. 

Chiropractic care is somewhat controversial with mainstream practitioners, including some who believe it is sustained by pseudo-scientific ideas such as subluxation and "innate intelligence" that are not based on sound research. In my own reviews of studies on chiropractic manipulation, I have not found evidence that it is effective long term for chronic pain, except for treatment of back pain.

However, chiropractic care is well established in the U.S. and Canada as a form of alternative treatment. It is often combined with other manual-therapy professions, including massage therapy, osteopathy and physical therapy.

Craniosacral Therapy

Craniosacral therapy (CST) takes a whole-person approach to healing, and the inter-connections of the mind, body and spirit. Practitioners say it is an effective form of treatment for a wide range of illnesses, and encourages vitality and a sense of well-being. Because it is non-invasive, it is suitable for people of all ages, including babies, children and the elderly. 

The intent of CST treatment is to enhance the body's own self-healing and self-regulating capabilities. This is done as the practitioner gently touches areas around the brain and spinal cord, which helps improve respiration and the functioning of the central nervous system. 

CST practitioners say it can help temporarily relieve a vast number of issues, including migraines and headaches, chronic neck and back pain, stress and tension-related disorders, brain and spinal cord injuries, chronic fatigue, fibromyalgia, TMJ syndrome, scoliosis, central nervous system disorders, post-traumatic stress, orthopedic problems, depression, anxiety and grief. 

Treatment costs range between $100 and $200 per session, and patients typically attend multiple times when chronic pain issues are being addressed. Some health insurance policies will cover CST.

Do I believe that CST will take pain away? No. But do I think it is a mindfulness tool that can help temporarily. Did it work for me? No, but it was worth a try since it is non-invasive. 

Again, I am spotlighting alternative therapy ideas that can help lower or reduce chronic pain.. Typical pain patients, including myself, find that it takes a variety of treatments to get pain levels low enough to consider it significant relief. The fact that they are treatments and lifestyle changes – and not cures -- is important to remember. 

I'd like to know if you've tried these methods and if they worked or didn’t work. The more we share our ideas and experiences, the better off others in pain will be in understanding different treatment options. 

Over the next few months I will spotlight more than 70 alternative treatments. Please only try what you are comfortable with and don’t put down others who are willing to try what they are interested in. 

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Chiropractic Therapy Gives ‘Modest’ Relief to Back Pain

By Pat Anson, Editor

When it comes to treating short-term back pain, spinal manipulation may not be all it’s cracked up to be.

In a review published in JAMA of over two dozen clinical trials involving over 1,700 patients, researchers said chiropractic adjustments provided only “modest” relief for acute low back pain – pain that lasts no more than 6 weeks.

The improvement in pain and function were considered “statistically significant,” but researchers said it was about the same as taking over-the-counter pain relievers. Over half of the patients also experienced side effects from having their spines manipulated, including increased pain, muscle stiffness and headache.

Although the study findings are mixed on the benefits of chiropractic treatment, the American Chiropractic Association (ACA) said it “adds to a growing body of recent research supporting the use of spinal manipulative therapy.”

“As the nation struggles to overcome the opioid crisis, research supporting non-drug treatments for pain should give patients and health care providers confidence that there are options that help avoid the risks and dependency associated with prescription medications,” said ACA President David Herd, DC.

Last month the ACA approved a resolution supporting new guidelines by the American College of Physicians (ACP), which recommend spinal manipulation, massage, heating pads and other non-drug therapies as first line treatments for chronic low back pain.

“By identifying and adopting guidelines that ACA believes reflect best practices based on the best available scientific evidence on low back pain, we hope not only to enhance outcomes but also to create greater consensus regarding patient care among chiropractors, other health care providers, payers and policy makers,” said Herd.

But the ACP guidelines are hardly a ringing endorsement of spinal manipulation. The overall evidence was considered low quality that chiropractic adjustments can “have a small effect on function” and that they provide “no difference in pain relief.”

In fact, the best treatment for acute low back pain may be none at all.

"Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment," said ACP President Nitin Damle, MD.

One in four adults will experience low back pain in the next three months, making it one of the most common reasons for Americans to visit a doctor. According to a 2016 Gallup survey, more than 35 million people visit a chiropractor annually.

Help Pain Patients Get Access to More Treatments

By Cindy Perlin, Guest Columnist

I just started a petition on change.org asking President Obama and Congress to give pain patients affordable access to safe, effective treatments. The petition points out that prescription painkillers, which are liberally reimbursed by health insurers, are causing addiction and death, while safer, more effective treatments are often inadequately covered or not covered at all.

The petition asks the President and members of Congress to support a Pain Treatment Parity Act that would require health insurers to cover all proven effective treatments for chronic pain on a level equal to coverage for pharmaceutical treatments. 

As I wrote in an earlier column on Pain News Network, the Act would eliminate preauthorization requirements and limits on the number of treatment sessions covered for services such as chiropractic and physical therapy; while also requiring coverage for acupuncture, biofeedback, massage, nutritional counseling, exercise programs, low level laser therapy and other safe, effective treatments.

The proposed legislation also requires physician education about these treatment modalities. Increases in fees for non-physician health care providers, who for the most part haven’t had a fee increase in over 35 years, would also be mandated.

My goal is to have over 100,000 signatures.  To find out more and to sign the petition, please click here.

Cindy Perlin is a Licensed Clinical Social Worker, certified biofeedback practitioner, chronic pain survivor and the author of “The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free.” 

For the last 25 years Cindy has helped her clients improve their emotional and physical well-being through her private practice near Albany, New York.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Insurers Should Cover All Types of Pain Treatment

By Cindy Perlin, Guest Columnist

Many chronic pain patients who have depended on opioids to manage their pain have posted comments critical of the CDC's draft guidelines and rightfully so.  No patient who is in severe chronic pain should be required to reduce their pain medication unless and until they have been provided with access to treatment that is at least as effective as their current opioid regimen.

Efforts to reduce use of opioids have driven legitimate pain patients to use of heroin and have not stemmed the opioid abuse epidemic. In fact, addiction and overdoses have only increased. 

Preventing addiction is the key to saving lives. The best way to do this is to reduce the number of new prescriptions for opioids unnecessarily dispensed to pain patients. Fortunately, curtailing opioid prescriptions can be done without harm to pain patients because safer, more effective treatments exist.

However, significant barriers to access to alternative pain treatments exist. Financial obstacles because of lack of insurance coverage, inadequate availability of services, and lack of knowledge of alternatives by both patients and their physicians prevent patients from receiving the most appropriate care. 

A significant factor that has led to inadequate availability of many pain treatments is the fact that non-physician in-network providers who are reimbursed by health insurers have not, for the most part, received any fee increases in over 35 years; whereas physicians have received numerous increases. These providers include chiropractors, physical therapists, occupational therapists, and mental health practitioners.

Availability of these services has decreased as more providers are leavingand fewer providers are entering these disciplines, because of a 65% decline in real wages owing to inflation.

To reduce these impediments to effective pain treatment, I propose a Pain Treatment Parity Act (PTPA), which would require all entities that pay for treatment of chronic pain -- including public and private insurers -- to cover all pain treatments that have credible evidence of effectiveness to the same degree that they cover pharmaceutical treatment of pain.

This includes both qualitative and quantitative limitations on care, such as equivalence in pre-treatment authorization requirements, limits on number of visits or dosage restrictions, copayment requirements, as well as equivalent fee schedules.

Provisions of the PTPA

1. All pain treatments with some credible evidence of effectiveness must be covered when provided by a licensed or certified provider. This includes any treatments with at least one well-designed randomized, controlled trial showing a significant benefit from the therapy and a good safety profile or any other reasonable evidence of safety and effectiveness.

Therapies that currently meet this standard include chiropractic, physical and occupational therapy, acupuncture, biofeedback, massage therapy, homeopathy, nutritional counseling and supplements, herbal therapy, psychotherapy, energy medicine therapy, supervised exercise programs, and multidisciplinary interventions, including coordination of services.

2. There can be no restrictions on the number of treatment visits or length of treatment for nonpharmaceutical pain treatment, unless there are similar restrictions on dosage or length of treatment for the preponderance of pharmaceutical treatments for pain.

3. Copays for visits to nonphysician pain treatment providers cannot exceed the copayment for primary care physician visits.

4. There cannot be a separate deductible for nonphysician pain treatment providers.

5. Preauthorization for visits to nonphysician pain treatment providers cannot be required unless preauthorization is required for pharmaceutical treatments for pain.

6. Medical necessity reviews cannot occur with greater frequency for nonphysician pain treatment providers than for physicians who provide pharmaceutical treatment for pain.

7. Fee schedules for in-network chiropractors, physical therapists, occupational therapists, psychologists, social workers, mental health counselors, acupuncturists, massage therapists, and all other nonphysician pain treatment providers must be increased by the same percentage as the average increase in fees for physicians for all specialties since 1980.

8. If an insurance plan has out-of-network benefits for medical and surgical treatments, it must also cover nonphysician out-of-network pain care providers at the same level of reimbursement.

9. All medical schools must offer a required course in pain management that covers all currently available treatments and the evidence supporting their use.

10. All physicians who treat chronic pain patients who have not completed a course in pain management in medical school must complete a 12-hour CME course about the safety and efficacy of all currently available treatments for chronic pain.

The Centers for Disease Control And Prevention (CDC) should champion this or similar legislation along with its opioid prescribing guidelines.

Cindy Perlin is a Licensed Clinical Social Worker, certified biofeedback practitioner, chronic pain survivor and the author of “The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free.” 

For the last 25 years Cindy has helped her clients improve their emotional and physical well-being through her private practice near Albany, New York.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Most Pain Patients Use Alternative Therapy (Video)

By Pat Anson, Editor

A large new study of chronic pain patients found that over half were using chiropractic care or acupuncture for pain relief, but many didn’t discuss their use of alternative therapy with their primary care providers.

Researchers surveyed over 6,000 patients in Oregon and Washington State who were Kaiser Permanente members and had three or more outpatient visits for chronic pain in 18 months.

The study, published in the American Journal of Managed Care, found that 58 percent of the patients had used chiropractic care, acupuncture, or both.

Over a third (35%) of the pain patients who had acupuncture never told their doctor, while 42% who had chiropractic care didn't talk to their providers about it. Almost all of the patients said they would be happy to share this information if their doctor had asked.

"Our study confirms that most of our patients with chronic pain are seeking complementary treatments to supplement the care we provide in the primary care setting," said Charles Elder, MD, lead author of the study and affiliate investigator at the Kaiser Permanente Center for Health Research. "The problem is that too often, doctors don't ask about this treatment, and patients don't volunteer the information.

"We want our patients to get better, so we need to ask them about the alternative and complementary approaches they are using. If we know what's working and what's not working, we can do a better job advising patients, and we may be able to recommend an approach they haven't tried,” said Elder, who is the lead physician for Kaiser Permanente's complementary and alternative medicine program.

The majority of the patients in the study (71 percent) were women, and the mean age was 61. Most suffered from back pain, joint pain, arthritis, neck and muscle pain, or headache.

The study was funded by a grant from the National Center for Complementary and Integrative Health.

A video report on the study that was produced by Kaiser Permanente can be seen here: