Wednesday, January 03, 2018 Study: Referral to Physical Therapy for LBP Reduces Odds of Later Opioid Prescription—Even When Patients Don't Follow Up on the Referral There's solid evidence that physical therapy as a first-line approach for low back pain (LBP) improves outcomes, but not many studies have focused on the factors that are associated with referral to physical therapy in the first place, regardless of later participation in treatment. Now authors of a recent study believe they've found associations indicating that the very act of referral for physical therapy may point to the ways a primary care provider's approach to LBP can affect patient perceptions and reduce odds of later opioid use, even when the patient doesn't follow through with the referral. The study, published in the Journal of the American Board of Family Medicine (abstract only available for free) looked at data from 454 Medicaid enrollees who were initially treated by a primary care provider for LBP, of which 215 received a referral for physical therapy. While researchers were interested in differences between the referral and nonreferral groups, the target of their study was something they believe is missing in current research: an examination of the entire referral population, regardless of whether those patients followed up with actual physical therapy. "Identifying only patients who have participated in [physical therapy] fails to account for the impact of the referral itself," authors write. "The referral potentially represents a provider-patient interaction about the nature of the LBP and prognosis. Improved outcomes among [physical therapy] cohorts may represent a combination of patient compliance with the [physical therapy] recommendation and a provider's beliefs about the nature and severity of the LBP." To get at this issue, researchers divided patients who received a physical therapy referral into 2 groups—those who, after a physical therapy consultation, went on to participate in physical therapy, and those who didn't—and compared those groups with each other, as well as with the group that didn't receive any referral to physical therapy. Among the findings: Patients receiving a physical therapy consult tended to be younger, and had received a radiograph and/or prescription for nonsteroidal anti-inflammatory drugs (NSAIDs) or muscle relaxers. Patients less likely to receive a consult were associated with tobacco use, chronic pain, depression, 2 or more comorbidities, and having received a referral for specialty care or advanced imaging. The odds of a patient receiving a physical therapy consult were increased 1.8 times if the patient also received an NSAID prescription. The odds of a patient receiving a physical therapy consult were decreased 25 times if the patient received specialty care or advanced imaging. In terms of actual participation in physical therapy, patients who received multiple orders from the primary care provider (specialty referrals, advanced imaging, etc) in addition to a physical therapy referral were less likely to go to physical therapy, as were older patients and those with 2 or more comorbidities. Opioid prescriptions were the most commonly used interventions during the year after the initial LPB visit. While the strongest predictor of a later opioid prescription was associated with whether an opioid prescription occurred at baseline, patients who received a physical therapy consult were 35% less likely to receive an opioid prescription, regardless of whether they participated in physical therapy after the consult. Participation in physical therapy had a "mixed impact" on health care use and no difference on overall costs. "These results highlight the impact of the initial provider visit and provide a foundation for future work understanding patient and provider beliefs surrounding the initial primary care visit for LBP," authors write, adding that "providing a physical therapy consult in place of an opioid prescription is a reasonable alternate strategy for pain management and improved function, particularly in this population of Medicaid enrollees." Researchers acknowledge the limitations of their work, including its population of 70% women, its focus on association rather than causation, and a reliance on electronic medical records that can limit insight into clinical decision-making. Still, they assert, the data they were able to tease out from patients who were recommended physical therapy point to some promising possibilities. "Patients with a consult to [physical therapy] represent a unique and important subset as the consult may represent a reflection of a provider's values and subsequent communication with the patient," they write. "Recommending [physical therapy] provides reassurance to patients that their LBP is best managed with physical activity and is in line with advice to stay active. This in itself has potential to change cost and health care use." Authors of the study include APTA members Anne Thackeray, PT, PhD; and Julie Fritz, PT, PhD, FAPTA. 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: Look for a special issue of Physical Therapy (PTJ) on nondrug management of pain coming in April.