Thursday, May 08, 2014 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.