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  • APTA Co-Sponsored Study: Seeing a PT First for LBP Lowers Odds of Early and Long-Term Opioid Use

    In this review: Observational retrospective study of the association of initial health care provider for new-onset low back pain with early and long-term opioid use
    (BMJ Open, September, 2019)

    The message
    An analysis of more than 200,000 commercial and Medicare Advantage insurance beneficiaries has revealed what researchers describe as a "significant" pattern: among patients seeking treatment for low back pain (LBP), those whose initial visit was with a physical therapist (PT), chiropractor, or acupuncturist decreased their odds of early opioid use by between 85% and 91%, and lowered their odds of long-term opioid use by 73% to 78% compared with those whose index visit was with a primary care physician (PCP).

    The study
    Researchers reviewed insurance claims from 216,504 adults with new-onset LBP between 2008 and 2013 to explore the relationship between the type of provider seen at the initial (index) visit and subsequent opioid use. The study looked at opioid use in terms of both "early" use, defined as a filled opioid prescription within 30 days of the index visit, and "long-term" use—a filled opioid prescription within 60 days of the index visit and either an opioid supply of 120 days or more over 12 months or a supply of 90 days and 10 or more opioid prescriptions over 12 months. The analysis included claims for patient visits, inpatient and outpatient treatment with initial providers, and pharmacy services.

    Authors of the study were also interested in gauging the impact of varying levels of direct access to PT visits as allowed in state laws, and evaluated rates of initial physical therapy use in states with access laws they defined as "limited," "provisional," and "unrestricted."

    The de-identified data, provided by OptumLabs®, included both commercial insurance and Medicare Advantage claims, and are described by authors as "representing a diverse mix of ages, ethnicities, and geographical regions across the USA." The study itself was sponsored by the American Physical Therapy Association (APTA) and UnitedHealthcare®, and included APTA members Christine McDonough, PT, PhD, and Julie Fritz, PT, PhD, FAPTA, among the authors.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, and insurance enrollment for at least 12 months before and after the index date), 53% initially met with a PCP. Among what authors call "conservative providers"—PTs, chiropractors, and acupuncturists—chiropractors were the most frequently seen, drawing 23.1% of patients, followed by PTs (1.6%), and acupuncturists (0.8%).
    • About 18% of patients filled an opioid prescription within 3 days of the index visit, and 22% received a fill within the first 30 days. Only 1.2% of patients met the researchers' criteria for long-term use.
    • In terms of early opioid use, patients who saw a PT first had 85% decreased odds of receiving an opioid fill within the first 30 days after the index visit compared with patients who saw a PCP first. Patients whose index visit was with an acupuncturist were associated with 91% decreased odds compared with PCPs, and those who saw a chiropractor first were correlated with 90% decreased odds.
    • The decreased odds of opioid use with conservative treatment also carried over to long-term use, with 73% decreased odds associated with a PT index visit, 74% decreased odds for acupuncturists, and 78% decreased odds for chiropractors compared with patients whose index visit was with a PCP.
    • Compared with states in which direct access to PTs is limited, patients in states with provisional access to PTs—for example, states that impose time or visit limits—had 21% increased odds of seeing a PT at index. Those odds increased to 67% in states with unrestricted direct access.
    • Compared with patients whose index visit was with a PCP, patients who saw other types of physicians, such as orthopedic surgeons and neurosurgeons, tended to have lower odds of early opioid use—but those lower odds disappeared when it came to long-term use.

    Why it matters
    This large-scale retrospective study—authors believe it's one of a very few to look at opioid use patterns across multiple providers—adds to the evidence that conservative approaches to LBP can significantly lower the odds of opioid use, an important consideration as the country continues to struggle with its opioid crisis.

    The bottom line, according to authors is that "early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based nonpharmacological approaches."

    More from the study
    Authors believe several factors might be at work when it comes to lower opioid use among patients whose index visit was with a conservative care provider:

    • These providers can't prescribe opioids, which may lower short-term use rates.
    • Patients who seek out conservative care providers may be doing so because they don't want to take opioids.
    • Conservative therapies tend to decrease LBP, lowering the need to seek other treatment.

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients, a factor that could influence the decision about which type of provider to see first. Researchers were also unable to dive more deeply into patient preferences and behavioral factors that might influence index visits and opioid use.

    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.

    [Editor's note: McDonough and Fritz are also the recipients of grants from the Foundation for Physical Therapy Research: McDonough received a Magistro Family Foundation Research Grant in 2015 as well as a New Investigator Fellowship Training Initiative in Health Services Research grant in 2009; Fritz was awarded an Orthopaedic Research Grant in 2002.]

    Comments

    • I think a reasonable solution would be having physical therapist in primary care. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2718095

      Posted by Daniel Kang -> >HW\=G on 9/25/2019 5:19 PM

    • I was excited when I read the title. It is unfortunate, and somewhat disappointing, that only 1.6% of patients in this study chose to see a PT first for low back pain. Less than 1% more than choosing acupuncture and largely less than the 23+% choosing chiropractic. With results being similar to chiropractic, physical therapy needs to do a much better job of marketing to the population with low back pain.

      Posted by Jim Farris on 9/25/2019 5:20 PM

    • In a study of low back pain soon to be published. Shaw reported on 1000 consecutive cases of low back pain. He used changes in apparent leg length and movement of the pelvis from asymmetry to symmetry to correctly identify and treat the anterior dysfunction of the sacroiliac joints. (11) He found that 98% of all patients had at least some degree of SIJD and his surgical incidence for herniated discs dropped to 0.2%. Shaw has been ignored. More recently Borowsky and Fagen have suggested that SIJD is far more common than is generally thought. (12) Murakami et al compared periarticular and intraarticular injections for diagnosis of dysfunction of the sacroiliac joint. (13) Using periarticular injections in 25 consecutive patients with SIJ pain they found that it was effective in all patients. Yeoman reported that sacroiliac arthritis was responsible for 36% of the cases of sciatica. (14) Davis and Lentle used technetium-99m stannous pyrophosphate bone scanning with quantitative sacroiliac scintigraphy in 50 female patients with idiopathic low back pain syndrome and found that 22 patients (44%) had sacroiliitis. Eight of these patients (36%) had unilateral sacroiliitis and 14 (64%) had bilateral sacroiliitis. Of the 22 patients with abnormal scans, 20 had normal radiographs. (14) Timgren and Soinila found and assessed the prevalence of reversible pelvic obliquity, its subgroups among a given population and the results of medical intervention. (15) Reversible pelvic obliquity proved to be unexpectedly common in 554 (98.4 %) cases and symmetry could be re-established in all but one case. Two manifestations of pelvic obliquity were iliac upslip and anterior rotation. The former caused seeming shortening of the leg and compensating scoliosis convex to side of the upslip and the latter seeming lengthening of the leg and a compensating scoliosis with contralateral convexity. In the follow-up visit, 78% of the patients reported improvement that was either significant or moderate in their functional ability and reduction of pain. A strong correlation exists between the maintenance of symmetry and the alleviation of the symptoms. (15A)

      Posted by Richard DonTigny, PT on 9/25/2019 7:01 PM

    • Now how do we get the public to learn and understandthis?

      Posted by Melinda Maul on 9/27/2019 9:53 PM

    • I put up a website over ten years ago. It gets over 5000 hits a week from 50 different countries including China and Russia. Here are a few articles on the SIJ. DonTigny Back Bibliography 1. DonTigny, RL: Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973 2. DonTigny, RL: Letter to Editor: Sciatica and the Sacroiliac Joint. PT March 1977, p 143 3. DonTigny, RL: Dysfunction of the sacroiliac joint and its treatment. JOSPT 1:13-25, 1979 4. DonTigny, RL: Function and pathomechanics of the sacroiliac joint. Phys Ther 65:35-44, 1985 5. DonTigny, RL: Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Phys Ther 70:250-265, 1990 6. DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990 7. DonTigny, RL: Sacroiliac joint as a major source of low back pain. Back Pain Monitor, April 1991, pp 55-58 8. DonTigny, RL: Sacroiliac joint dysfunction responds well to manual therapy. Back Pain Monitor, May 1991 9. DonTigny, RL: Mechanics and treatment of the sacroiliac joint. Journal of Manual & Manipulative Therapy, 1:3-12, 1993 10. DonTigny, RL: Function of the lumbosacroiliac complex as a self-compensating force couple with a variable, force-dependent transverse axis: A theoretical analysis. JMMT, 2:87-93, 1994 11. DonTigny, RL: The DonTigny low back pain management program. JMMT, 2:163-168, 1994 12. DonTigny, RL: Functional Biomechanics and Management of the Pathomechanics of the Sacroiliac Joint. In Dorman TA (ed): SPINE: State of the Art Reviews. Philadelphia, PA, Hanley & Belfus, Inc. 1995, Chpt 14 13. DonTigny, RL: Critical analysis of the sequence and extent of the result of the pathological release of self- bracing of the sacroiliac joint. Concurrently in JMMT 7:173-181, 1999 and J of Ortho Med (UK) 22:16-23,2000 14. DonTigny, RL: Critical analysis of the functional dynamics of the sacroiliac joints as they pertain to normal gait. J of Orthopaedic Medicine (UK) 27:3-10, 2005 15. DonTigny, RL: Pathology of the sacroiliac joint, its effect on normal gait and its correction. J of Orthopaedic Medicine (UK) 27:61-69, 2005 16. 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 17. DonTigny, RL: Sacroiliac 101; Form and Function; A biomechanical study. Journal of Prolotherapy 3:561-567, 2011 Available in full text from https://www.researchgate.net 18. DonTigny, RL: Sacroiliac 201; Dysfunction and Management: A biomechanical solution. Journal of Prolotherapy 3:644-652, 2011 Available in full text from https://www.researchgate.net DonTigny, Richard: The Sacral X Axes: Location, Structure, Movement, Parallel Kinetic Ligamentous Loading, Function, Biotensegrity Technology and Pathology. The Essential Pieces of the Low Back Pain Puzzle. (June 18, 2017). Available at SSRN: https://ssrn.com/abstract=2988680 Chronic and acute low back pain and its relationship to the sacral x axis, leg length changes, sciatica. abdominal pain, idiopathic scoliosis and incontinence.

      Posted by Richard DonTigny, PT on 10/11/2019 10:06 PM

    • I appreciate the very informed comment by Richard DonTigny. He's been telling us these things for decades and regrettably, seems to have been largely ignored. In fact, upon retiring recently and cleaning out old notebooks, I found a paper of a well done study from 1927 (if I recall correctly) that said pretty much the same thing. And even with all this evidence, do you think UnitedHealthcare, one of the sponsors of this study, will recognize our value? I doubt it. They'll just find another angle to cut our reimbursement even further. One of the great joys of retirement is knowing I'll never have to deal with them again. Congratulations Richard on still being "in the saddle". I greatly appreciate and value what I learned from reading your papers. The younger PT generations should know more about your work.

      Posted by Brian Miller on 10/11/2019 11:14 PM

    • In my opinion we need well organized programs to educate the patient about LBP and how physical therapy as conservative treatment is should be the initial part of POC

      Posted by Angel on 10/17/2019 1:54 PM

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