Some back pain-identified as a red flag-should not be treated with exercise and requires a much more careful medical workup. Rational treatment must have a conceptual framework, standardized assessment/treatment, and a common therapeutic protocol. However, clinical monitoring is important because clinicians need to ask legitimate questions, such as “How much physical therapy and chiropractic treatment is placebo?” Although language like this tends to cause offense to certain patient or clinical populations, the question is meaningful. The operative words here are “as painless and cost effective as possible,” because any clinical monitoring system faces incorporation challenges. 5 The National Institutes of Health (NIH) has been in the process of completing and implementing its Patient Reported Outcomes Measurement Information System (PROMIS) 6 that was created to make the acquisition of patient-reported outcomes as painless and cost effective as possible. Practices will be required to provide objective, evidence-based treatments with measurable outcomes. 4 The effects of the Patient Protection and Affordable Care Act are still somewhat uncertain, with one clear exception. 3 In addition, the direct costs and the indirect expenditures of absenteeism, as well as presenteeism (lost productivity while still on the job), are estimated to be even greater. Much of the practice of musculoskeletal medicine is far from evidence-based, and costs for the management of back pain in the US also continue to escalate, by as much as $100 billion. The US gross domestic product (GDP) is $15.6 trillion, with healthcare accounting for nearly $3 trillion of that figure, 1, 2 and healthcare costs are rampantly rising. The United States healthcare system has found itself in the unenviable position of being on a pathway to bankruptcy.
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