Unconventional Care for Spine Pain Outperforms Usual Treatment in Rigorous Clinical Trial

Research finds nontraditional treatment options for back and neck pain can be more effective

If back pain is making you miserable, you’re far from alone. The most common of all health maladies, back pain affects 29% of US adults and one out of seven of adults battles neck pain.

Now newly published results from a large randomized clinical trial discovered that for many patients, unconventional treatment options were as good or better at treating spine pain than usual medical care. Led by Stanford Professor Arnold Milstein and Harvard Professor Niteesh Choudhry, the study’s findings were published in the Journal of the American Medical Association.

The trial compared two care methods emphasizing patients’ capacity to manage their spine pain to usual medical care that places more emphasis on imaging, injections, surgery, and opioid prescriptions.  

After eliminating rare patients with rare causes of spine pain such as tumors or diverse nerve compression, researchers tested the unconventional care methods with several thousand spine pain sufferers seeking medical care.

Both unconventional care methods were clear winners, delivering superior pain relief measured 3 and 12 months after enrollment in the trial. Superior pain relief compared to usual medical care continued to increase beyond the 6-to-8-week duration of both unconventional treatments.

"Our trial results demonstrate that after screening out patients with very rare emergent conditions, primary care physicians would better serve their patients by referring them to either of the two unconventional care methods that we tested.

“Each of the patients in our trial started their search for pain relief with a visit to primary care,” said Milstein, director of Stanford’s Clinical Excellence Research Center (CERC) and the study’s senior author. “Our trial results demonstrate that after screening out patients with very rare emergent conditions, primary care physicians would better serve their patients by referring them to either of the two unconventional care methods that we tested.” Milstein also emphasized the trial’s finding for one of the two unconventional care methods was associated with lower total spine care spending. “Better patient outcomes with less spending are achievable but only if US health care systems and health insurers much more heavily prioritize improving value for patients.”

Two different approaches, two encouraging results

One unconventional method, “individual postural therapy,” or IPT, focuses on patient education and exercises to improve posture and balance. It is delivered in up to eight weekly sessions at clinics by non-medical therapists certified in the Egoscue Method, an approach already available in the US and internationally. The method was formulated by a US military veteran who had received little benefit from conventional medical spine pain care.  

The second unconventional treatment was designed and refined by early-career physician research fellows at CERC.  The design reflected a year-long examination of previously published spine pain outcomes research findings and site visits to health care teams nationally reputed to be delivering exceptionally cost-effective spine pain care.

The young care “re-designers” nicknamed their new care method “ICE” based on its 3-step sequence of “identify, coordinate and enhance.”  Most ICE patients receive rapid single-session physical therapy, non-opioid over-the-counter pain relief medication, and a single telephone-based coaching session in pain self-management. However, if a brief initial survey of patients seeking conventional spine pain care indicates that a patient is prone to “catastrophize” their pain, they receive three PT visits, three health coach calls, and tele-consultations with a clinician.

Though neither unconventional model is currently Integrated into primary care at scale, some components are already in wide use. “We tested the interventions in a way that could be easily integrated into primary care, so implementing them in other practice settings should be quite straightforward,” said Choudhry, MD, PhD, of Brigham and Women's Hospital and Harvard Medical School in Boston. Choudhry was the paper’s lead author.

Study enrollment began in June 2017, with final follow-up on March 31, 2021. The trial was conducted at 33 primary care clinics in the US, including 12 clinics affiliated with Vanderbilt Medical Center. CERC affiliated scholar Sheila Fifer, PhD, and Constance Fontanet, MPH, of Brigham and Women’s Hospital and Harvard Medical School were contributing authors and intensively involved in trial management and analysis of trial results.

In addition to outperforming usual medical care on spine pain reduction, both unconventional spine care methods studied in the trial reduced costs associated with diagnostic imaging, invasive procedures, and specialist visits. Back and neck pain treatment accounts for the highest share of health care spending in the US, totaling an estimated $134.5 billion in 2016.