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  • Family Physician Use of LBP Risk Stratification Could Improve Timely Referrals to PTs

    Research from the United Kingdom asserts that family physicians' use of risk-stratified care for low back pain (LBP) has produced "significant improvements in patient disability outcomes" through the application of a system first studied in physical therapist services.

    In an accompanying editorial, authors Timothy S. Carey, MD, MPH, and Janet Freburger, PT, PhD, give "a qualified 'yes'" to the question of whether the system should be attempted in the United States, "where practice acts, third-party payer requirements, and other barriers limit the patient's ability to directly seek care of physical therapists." The research results and editorial appear in the March/April issue of Annals of Family Medicine.

    The project, dubbed "The IMPaCT Back Study," (Implementation to improve patient care through targeted treatment) compared 922 patients presenting with low back pain who received "usual" care with those who received stratified care. This stratified care approach was based on a system developed for a previous study involving physical therapy in the UK. In that study, PTs classified patients as being in a low, medium, or high-risk group for persistent disability and provided treatment matched to the risk level.

    The tool adopted for family physician use consisted of 9 self-report items that addressed function, radiating leg pain, pain elsewhere, depression, anxiety, fear avoidance, catastrophizing, and "bothersomeness." Scores from the assessment placed patients into 1 of the 3 groups. Low-risk groups received education on self-management, advice to stay active, pain medications when appropriate, and reassurance that their prognosis was good. Family physicians referred patients in the medium-risk and high-risk groups to physical therapy, and focused on treatment of the concerns revealed in the stratification tool.

    Researchers compared the usual and stratified treatment groups after 6 months by way of self-report questionnaires and through tracking physician clinical behavior including number of physical therapy referrals, use of tests, medication prescriptions, reconsultations, and sickness certifications. In the end, they found that while aggregated improvement in patient outcomes was "modest" compared with usual treatment, patients in the medium and high-risk groups received more physical therapy and reported marked improvements in self-reported pain and time off work.

    The study's authors believe that the most significant findings have to do with the ways in which stratified care creates a more "targeted" use of health care resources, and results in fewer sick certifications and work days missed—about half of the average time off rates of the usual-care group.

    "Improvements in the management of low back pain are needed, yet changing behavior among family physicians is an identified challenge as clinicians struggle to have the time, skills, or inclination to translate evidence into practice to improve patient care," the authors write.

    While editorial authors cautiously a similar program in the US, they point out that implementation will require careful consideration of the practice competencies of PTs receiving referrals, given that the high-risk group requires psychologically informed physical therapy that employs elements of cognitive-behavioral therapy. "This high-risk protocol … is in its infancy in the field of physical therapy," they write, and may require some expansion of what they describe as "extremely limited" training in this area. The authors also speculate that the system would need to be "adapted" for effective use in the US.

    Still, they write, the low cost of implementation and its similarity to other screening instruments already used in primary care—tools that assess alcohol misuse or depression, for example—suggest that barriers to use are minimal. "These advances don't solve our problems with the large disability burden and high costs of low back pain, but they represent a promising start."

    Research-related stories featured in News Now 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.

    South Carolina Circuit Court Upholds Ban on Physician Referral for Profit

    In the latest chapter in a decade-long battle in South Carolina over the issue of physician-owned physical therapy services (POPTS), a circuit court on April 22 granted summary judgment (.pdf) in favor of the South Carolina Board of Physical Therapy Examiners (SCBPTE) and the South Carolina Chapter of APTA (SCAPTA). In its ruling, the court upheld the ability of physical therapists (PTs) to operate group practices while maintaining the state's ban on PTs working for physician owned groups.

    The case is a sequel to the 2006 opinion of the State Supreme Court in the Sloan litigation involving a practice act clause that prohibits a physical therapist (PT) from dividing revenue with a person who referred a patient. The Supreme Court interpreted the act as prohibiting a PT from working for pay for a physician-owned group if the PT treats patients referred by a physician in the group. SCAPTA has defended the law from several legislative attempts to repeal it.

    The circuit court case was brought by 2 medical doctors and 1 PT against the SCBPTE. The plaintiffs argued that the act’s prohibition should also apply to PTs who work for pay for a PT-owned group if the PT treats patient sent to him/her by another PT in the group. Such an interpretation would prevent PTs from operating group practices. The summary judgment ruled against this interpretation.

    Soon after the case was filed in 2013, SCAPTA entered a motion to intervene in the case, which was granted by the court. APTA provided significant legal resources to the chapter, and the APTA Board of Directors approved a grant to help cover the chapter’s substantial legal bills.

    The battle over interpretation of the law is probably not over—plaintiffs are expected to appeal this decision, which could lead to the case being reviewed in the state supreme court. At the same time, supporters of a repeal of the POPTS restrictions could make another attempt to undermine the entire law.

    WHO: MERS Likely No More Transmissible Than Before, Still a Serious Illness

    The uptick in Middle East Respiratory Syndrome (MERS) cases that caught US media attention when the first case was reported in the United States is most likely the result of seasonal changes, and not due to an increase in transmissibility of the disease, according the United Nations' World Health Organization (WHO). The announcement was made in a May 7 WHO statement that attributes the rise in part "to breaches in WHO’s recommended infection prevention and control measures" in some Saudi Arabian health care facilities.

    MERS is a viral respiratory illness first reported in Saudi Arabia in 2012 caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness, and about 30% of these people died. Recently, the first case of MERS in the US was reported in a health care worker who had just returned from the Arabian peninsula and been in direct contact with an individual with MERS. That health care worker is anticipated to be released from the hospital soon.

    The spread of the virus has been among individuals who were in close contact with patients who were infected. The incubation period is from 2 to 14 days, and researchers believe individuals are not contagious during the incubation period. If a patient is suspected to have the virus, then standard contact and airborne precautions are recommended.

    For more information on MERS protocols, visit the the US Centers for Disease Control and Prevention (CDC) webpage on interim prevention and control recommendations around MERS. Although it does not address MERS specifically, APTA's infectious disease control webpage helps physical therapists (PTs) and physical therapist assistants (PTAs) understand the protocols for reducing risk of disease transmission. APTA staff will continue to monitor the situation and add resources as they are needed.