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  • Study: Seeing a PT First for LBP Lowers Overall Costs, Reduces Chances of Later Opioid Prescription

    A new study has added to the growing body of evidence that beyond its effectiveness as a treatment for the pain itself, there are additional benefits to receiving physical therapy for low back pain (LBP) as a first-line approach: doing so could save money and dramatically reduce the chance of receiving an opioid prescription down the road.

    The study, published in Health Services Research (abstract only available for free), tracked private insurance information from nearly 150,000 patients for 1 year after an initial visit for LBP. Researchers were interested in identifying any differences in the kind of health care used and how much it cost over the course of a year among patients who saw a physical therapist (PT) first, those who saw a PT at a later time after an initial visit with another provider, and those who never visited a PT during the study period. To qualify for the study, patients had to have no prior history of LBP, back surgery, or other conditions that may have caused back pain.

    The conclusion: patients with LBP who received care from a PT first experienced lower out-of-pocket, pharmacy, and outpatient costs after 1 year and reduced their likelihood of receiving an opioid prescription by 87% compared with patients who never visited a PT. The PT-first group also was associated with a 28% lower probability of having imaging services and 15% lower odds of making a visit to an emergency department. The results caught the attention of National Public Radio, the Orlando Sentinel, and other media outlets.

    The cost savings for the PT-first group weren't across the board, however; researchers found that patients who visited a PT first recorded higher provider costs during the study period, a difference authors believe may be related to "a higher frequency of visits that are common for physical therapy care." However, authors point out, those higher costs are offset by the lower outpatient and pharmacy costs among the PT-first group.

    Another wrinkle: the PT-first group was associated with a 19.3% higher probability of later hospitalization. Again, the researchers weren't particularly surprised.

    "Having inpatient hospitalization is not necessarily a bad outcome for a patient," authors write. "PTs provide care that aims to resolve LBP by addressing musculoskeletal causes first, but if this problem does not get resolved, PTs may refer patients appropriately for more specialized care." Additionally, they point out, the hospital costs themselves were not significantly different from the non-PT and later-PT groups, suggesting that "seeing a PT first did not necessarily result in additional costly complications."

    Authors point to the drop in opioid prescriptions as an especially timely finding, writing that "Opioid overdoses have reached epidemic proportions, and opioids have not been found to significantly improve health outcomes. First-line, nonpharmacological methods to treat LBP have been recommended in the literature; this study suggests that [physical therapy] may be a positive alternative."

    As for prevalence of visiting a PT first for LBP, researchers found that 8.7% of patients were PT-first, 80% of patients made no PT visits, and 11.5% visited a PT at a later time after the initial diagnosis of LBP. In addition to PTs, the most common provider types seen at the first point of care were chiropractors (49.6%), orthopedists (9.4%), and acupuncturists (7.8%). A general grouping of "other providers" were seen by 15% of the patients studied. Those visiting a PT first were more likely to be female, younger, in an open-network insurance plan, and to have fewer comorbidities.

    Researchers believe that given the results of this and other studies, it's time states and insurers take a closer look at their direct access provisions to make it easier for patients to receive the more effective, safer, and lower-cost care that a PT can offer—and then make efforts to educate their residents and beneficiaries on the availability of PT services.

    "Some patients who may benefit from seeing a PT early, however, do not have access, sometimes because of regulatory and health insurance restrictions and, often, patient awareness," authors write. "Given the findings of this study, states should consider reviewing their laws that restrict direct access to physical therapy services and insurers should assess their policies."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • I sure would like to see a study that looks at the frequencies for re-injury for those with PT visits 1st vs those without PT.

      Posted by Sean Carey on 6/8/2018 3:27 PM

    • PTJ rejected my manuscript on the immediate relief of low back pain four times in 1968 and 1969 and then told me to try a different journal. ( DonTigny, RL: Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973). If you are not using the sacral x axis now then you are still years behind in your biomechanics and treatment. 1. DonTigny, RL: A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction. In Vleeming A, Mooney V, Stoeckart R (eds): Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier). Edinburgh, 2007, pp 265-279 2. DonTigny, RL: Sacroiliac 101; Form and Function; A biomechanical study .Journal of Prolotherapy 3:561-567, 2011 3. DonTigny, RL: Sacroiliac 201; Dysfunction and Management: A biomechanical solution. Journal of Prolotherapy 3:644-652, 201 4. DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990 5. DonTigny RL:The Cause of Acute and Chronic Low Back Pain as a Reversible Pathology at the Sacral X Axes. (First Revision) November 22, 2017, www.researchgate.com DOI: 10.13140/RG.2.2.29972.50561 SSRN: https://ssrn.com/abstract=2988680.

      Posted by Richard DonTigny, PT on 6/8/2018 6:11 PM

    • Part of my training in Australia (back when dinosaurs roamed the earth) included Emergency Room training. At that time it involved only cursory evaluations then applying casts for fractures, Ambulatory aide (walkers/crutches/cane) instruction, TENs unit instruction, Low back care education etc. Perhaps having PTs (now as musculoskeletal specialists) back in the ER working closely with physicians, assistants, nurse practitioners and nurses is something to reconsider and most certainly would reduce the immediate prescription of opioids. Lebec, M. T., & Jogodka, C. E. (2009). The physical therapist as a musculoskeletal specialist in the emergency department. Journal of orthopaedic & sports physical therapy, 39(3), 221-229.

      Posted by Kylie on 6/11/2018 7:06 PM

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