Wednesday, January 30, 2019 Systematic Review: LBP Studies Make the Case for Early Physical Therapy Authors of a new systematic review of 11 studies on low back pain (LBP) have found that despite sometimes-wide variation in research design, a picture of the value of early physical therapy for the condition is emerging—and the results are encouraging. According to the review, e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free), evidence supports the cost-effectiveness and better patient outcomes of early physical therapy over later physical therapy for LBP, and even points to a correlation between early physical therapy and lower rates of opioid prescription overall. As for utilization and costs associated with early physical therapy versus so-called "usual care" (UC)? Early treatment by a physical therapist (PT) adhering to APTA guidelines could make a positive difference there as well, authors say, but that's a harder question to answer definitively until studies become more uniform in terminology and design. The review synthesized data from 11 studies narrowed down from an initial pool of 1,146 articles. Authors aimed not only to compare early versus late physical therapy for LBP, but also to assess early physical therapy against UC that didn't include physical therapy (at least not initially, for some of the studies). Four of the studies were randomized controlled trials (RCTs), 6 were retrospective cohort studies, and 1 was a prospective cohort study. Study sizes ranged from 60 to 753,450 individuals. The studies were focused on new episodes of LBP, and did not address physical therapy as prevention. It didn't take long for authors of the review to realize they were up against some challenges in synthesizing the studies' results, mostly because of the variation in ways the individual projects were set up and conducted. Variation included the timeframes researchers used to define "early," "delayed," and "late" physical therapy, the inclusion of an option for later physical therapy in UC groups in some studies, and the variability of "education" components that were sometimes included in the UC groups, which in 2 RCTs included advice to remain physically active. Still, authors of the review were able to identify at least 1 common pattern: in the 6 studies that compared early physical therapy with late physical therapy for LBP, 5 "demonstrated significant reductions in HSU [health services utilization]." Those reductions ranged from an estimated savings of $1,209 after 24 months to $2,991 after 1 year (for a study that compared late physical therapy with "immediate" physical therapy). Early physical therapy also reduced the likelihood of later opioid use, spine injection, and spine surgery compared with late physical therapy. When it came to early physical therapy versus UC for LBP, the results were inconclusive, the authors write—2 out of 3 studies that assessed cost found a higher price tag associated with early physical therapy. What makes these results inconclusive, according to the researchers, is that there are simply too many unexplored variables related to "patient characteristics, care-seeking patterns, and physician decision-making." "Patients who participate in early [physical therapy] may also be fundamentally different from patients who follow the usual care pathway," the authors write. "Additionally, not all people with LBP go on to seek medical care. Estimates of the proportion of individuals experiencing LBP who seek care is highly variable…with percentages ranging from 9.19% in some geographic locations to 44.5% in others." As for the patients who seek physical therapy versus usual care, authors say the patients are more likely female, have higher educational levels, and have higher income compared with those who seek UC. "Therefore, patients who participate in early PT…may be part of a care-seeking group that is more active in seeking treatment than those who receive usual care, who may take a more passive approach," the authors write. "These traits may lead the early PT group to utilize more health services compared to the usual group." Finally, authors write, earlier studies "support the idea that not only does adherence to APTA guidelines for acute LBP decrease risk of later HSU, but nonadherence to APTA guidelines and ineffective [physical therapy] treatments could potentially increase future use of health services." The problem is that most of the studies included in the review were unclear about whether or how often the physical therapy interventions adhered to the guidelines. Despite the mixed results, the authors believe their findings "support early access to [physical therapy] as a cost-effective intervention for acute LBP that reduces HSU," adding that "receiving early [physical therapy] for acute LBP could not only reduce health care costs, but it may also help combat the opioid crisis "Early [physical therapy] for acute LBP…may prevent the potential for recurrences and chronic pain, leading downstream cost savings and better outcomes for individuals," the authors write. "Even if recurrences do occur, which is fairly likely, early [physical therapy] can give people with new episodes of LBP strategies to manage their condition independently in the future, preventing unnecessary overuse of resources." APTA members Elizabeth Arnold, SPT; Janna La Barie, SPT; Lisely Da Silva, SPT; Meagan Patti, SPT; Adam Goode, PT, DPT, PhD; and Derek Clewley, DPT, PhD, co-authored the study. 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.