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Ojha HA, Wyrsta NJ, Davenport TE, Egan WE, Gellhorn AC. Timing of physical therapy initiation for non surgical management of musculoskeletal disorders and effects on patient outcomes: a systematic review. J Ortho Sport Phys Ther. 2016; 46(2):57-70.
The purpose of this systematic review was very clear: to review the published literature regarding early versus delayed physical therapy for musculoskeletal conditions and the relative effects regarding patient outcomes and cost.
Although 3135 articles were scanned for relevance, only 14 were deemed appropriate for the final review. Interestingly, all 14 articles examined early versus delayed treatment of neck and low back pain; that is, there were no studies examining early versus delayed PT for other musculoskeletal conditions (e.g., ankle sprain).
There was low grade evidence that early initiation of PT was associated with reduced cost (~$1200-2700 lower), medical utilization (advanced imaging, surgeries, injections, physician visits, opioid medications), and reduced indemnity and sick leave with improved ability to lift and carry in work related injuries.
There was low to very low grade evidence that there are no differences in body functions and non-work related disability and function between those who receive early vs. delayed physical therapy.
The authors wisely draw attention to the fact that in all studies considered, early physical therapy was never associated with decreased patient outcomes or an increase in cost/medical utilization.
The authors conclude by stating, “physical therapy should be initiated as early as is feasible to minimize cost, medical utilization, and potential iatrogenic harm.”
I choose this article for our discussion board post this month, not only because I was interested in it’s content, but because I thought it would provide for some good reflection and discussion. A few questions to consider:
– Why do you suspect that the current U.S. medical guidelines include waiting to refer patients for physical therapy for spinal related pain 6 weeks after onset of symptoms? Are there times when taking a “wait and see” approach are appropriate? Why or why not/any examples?
– There was a noted reduction in cost and medical utilization, however not in function or disability (with the exception of quicker return to work). Why do you suppose this to be the case? In other words, how do our services work to reduce cost and subsequent medical utilization yet at the same time may not be so effective at reducing pain and disability?
– What are the current barriers to early referral for physical therapy?
– Are there other conditions that would make for good studies regarding the efficacy of early versus delayed PT, seeing that there currently are none published?
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1. I suspect the current guidelines are based on the age-old theory that most back pain gets better on its own, therefore no intervention is necessary and patients will get better by staying active and with time. “Self-care” will be sufficient for 6 weeks, then if that is not successful, then other conservative treatment options can be taken. Yes, I do think this is appropriate in some cases like first offenses that are mild in nature and non-neurogenic. With that said, there is a reason why the back pain initially occurred and I think we have a lot that we can offer patients in terms of prevention of future occurrences, body mechanics, exercise form, and self-management strategies.
2. With large systematic reviews, it’s hard to be homogeneous when it comes to concluding an overall treatment effect without looking at the specifics of the articles included in the review. That’s one of the only problems that I have with this article is how much variety there was within the treatments that were listed for physical therapy. Passive treatments including ultrasound/TENS, active exercise, manual therapy, functional training, stress management, some articles didn’t even list what treatments they included. Even listing “exercise” as one of the treatments is vague and one of the things that successful physical therapists do well is provide a very specific, individualized approach for exercise prescription. General exercise vs. specific, functional exercise prescription could make or break a recovery. Maybe this is somewhere we lose the real, significant effect on function and pain.
3. Knowledge and presence in the community are huge barriers. I don’t think the general population knows what we have to offer or even knows that it’s an option to come to us first. It’s frustrating to say the least. Direct access is so important to progress our field and to make sure we keep pushing for our role as musculoskeletal and movement experts. On the other hand, so much of our credibility of our treatments is based on literature and systematic reviews like this one can be shared to compile the trends in data. More studies can create more support, then can create change in practice patterns.
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This got me thinking about a patient I just evaluated last week – mild low back pain that I hypothesized as low lumbar facet dysfunction, came in through direct access because he had some family members who had success with other PT’s our clinic. He presented with pretty low level deficits and had this pain for only about 4 weeks, and is getting much better anyways on his own. But what was so awesome about what we could do was the fact that he worked right upstairs, so we went to his office during the eval and problem solved right there what could be contributing to his back pain (monitors, keyboard, mouse all off to the left). With some other education about self-management and treatment using manual therapy, I felt like that was the most successful eval I had all week, month, etc. because we addressed causation and self-management strategies right off the bat. Let’s be honest, this doesn’t happen often but I wish so bad it was more the norm!
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It’s interesting how many docs take the “wait and see” approach. A potential reason could be to see if medication work. As well, the mentality of resting is important when it comes to healing a sprained ankle or wrist. When it comes to the spine, we are constantly using postural muscles. Staying away from lifting/ aggravating factors are important. I feel it is necessary to educate physicians on the importance of movement patterns and maladaptive behaviors. It was interesting how “more than 70% of cases with low back pain only needed 1 PT visit and less than 3% of the referred LBP patients required referral to an orthopaedic specialist”.
I agree with Laura when she talks about the limitations in specificity through some literature. I think it is important to classify patients with acute low back pain into specific categories because we know the classification method has had great results in outcomes.
There are so many barriers when it comes to early referral for physical therapy. People are just now realizing the use of direct access. Educating the population/ our patients on direct access and early PT is key. We need to show them how compensation patterns potentially could lead to more injury. We’ve done fitness screens at local fitness centers and we ended up getting several direct access patients.
I would love to see an article published on what LB pathology/ signs and symptoms would be perfect for early PT. I had a patient from a previous rotation who slept wrong. After analyzing movement, I found that she had a hypomobile segment. She fit the criteria for a lumbar manip. Post manip she was back to normal and felt great. I talked about a POC and the importance of exercise. She was satisfied and saw no need for more appointments. Since then, I never heard back from her.
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Oksana, it sounds like you guys do great work with fitness screens and getting the word out there for our role. Cheers to that!
How do you determine the certain patients and certain injuries that have an increased risk for prolonged/recurrent disability? Who makes that call and how do we pinpoint those people out in the community without waiting until they become chronic?
What would you do in this case? A 28 year old male healthy, fit accountant has a back spasm after a workout. He usually does power lifting with his buddies but hasn’t had any real training with form, mechanics, etc. He sits at a desk for 10-12 hours a day, then works out intensely at night. He deals with the muscle spasm for a few days, then gets on with his life and doesn’t change anything. Then, he gets another back spasm a few weeks later with the same workout. Has to deal with it again that puts him out for a few days again.
Is there a place for us here? Would you agree that 1 or 2 sessions of looking at mechanics and form would be beneficial for him, maybe looking at his work habits contributing to the problem?
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Great question- I use the severity/ irritability scale on those patients. I see what’s important for them and/or how that limits their functional performance. I first think about common pathologies that I could see ie: shoulder impingement from bench pressing, scapular dyskinesia with assist; knee: PFPS (potentially due to imbalance to ABD and ADD). I make sure I gather some subjective and objective data. Education is key.
It makes since a guy who is stationary and then works out hard presents with spasms. I would first check out his MOI, postural habits, typical routines, and educate him about stability exercises while he’s at work. I would also find out his warm up/ cool down technique. As well, I know magnesium glycinate in right dose is great for calming down spasms.
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Laura & Nick – I think you both made great points about early intervention, regarding waiting vs. treating and I think there are definitely cases where somebody may not need any intervention.
Even though someone who may not need a whole lot of treatment for a first episode of LBP, just a couple of visits could be very beneficial to modify behavior and movement patterns and likely prevent future problems.
The issue there is that our literature isn’t great at supporting very specific treatments (as Laura pointed out) and early outcomes. Even if this would result in utilizing PT and health are dollars more than current common practice, 1-2 visits would still be cheaper than imaging, MD visits and meds etc. Additionally, I think if this were more common, people in general would become more aware of PT as a direct access option and hopefully, would come in earlier for more severe issues.Last week, I evaluated a guy for neck/upper quarter pain that started 4 days before (specific mechanism). Aaron had treated him for a few months for LBP last year and this pt told me that his first impulse last week was to come in and have a PT check it out instead of going to the MD, or ER. It was easy to tell that having had successful PT and good education completely changed his perspective on care. I saw him twice and he called in saying that he felt better and was good with his HEP. I’m guessing if he would’ve waited a couple of months or longer to come in, there’s no way he would’ve improved as quickly.
Another new pt I had last week had been seen at our clinic for LBP a couple of years ago and it recently came back after having been asymptomatic since. He told me when he was first sent for PT back then he thought PT was BS (he didn’t hold back in regards to language). He then added that looking back he feels stupid (his words) and he’d never consider any other treatment option before doing PT.
I think a huge part is education and promotion. Mark Jones talked a little about how they have ads and public education for PT in Australia and that’s definitively something we could use here.
Laura – I think that case is 100% our place. That being said, appropriate and honest self promotion is vital there. I wouldn’t say that all PTs I know have the appropriate background to fully assess power lifting movements, which raises the question whether or not they should and whether that would be considered entry level PT knowledge. I’d say yes. Thoughts?
Granted, there are lots of personal trainers who know a great deal about those movements and how to correct poor form, but in my opinion that is one of the areas that we as a profession should claim more for ourselves and send them to the personal trainer after, or get them to a point where they can perform those kinds of movements safely. -
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You guys are killing it.
Great discussion – introspection, excellent thought out statements across the board.
I seem to lean more toward Nick’s points.
90% of people have a lower back pain episode in their lifetime. The majority are self limiting; many do not need to seek any sort of healthcare. How many Physical Therapists have had lower back pain? Alot. How many go seek care, miss work, become disabled? None. Education/knowledge of tissue, pain, healing, expectations of symptoms are part of our understanding of an acute nocioceptive event. Because of that knowledge, we cope/confront and move on.
Who we need to screen early on and begin PT early, are those with acute lower back pain that are at risk for poorly coping with the episode.
Those are primarily psycho social factors: Yellow flags. Related to emotions, beliefs, attitudes, behaviors, family, work factors.
We’ll talk more on Sunday.
We have screening/outcome tools to use to address these attitudes/behaviors (ODI/NDI, FABQ, PHQ-2; TSK, lots more). Utilizing them to recognize the patients that may require earlier versus later PT.
Keep talking – great stuff.
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I think the PT with back pain example is great, because it shows how much of a difference education makes.
There’s already research on how good of an outcome predictor education is, even compared to imaging findings etc. An interesting study would be having individuals with a first episode of likely self-limiting LBP with an experimental group receiving all the pain science education vs. a control group.
Maybe adding another group receiving pain science ed + postural re-ed/TE.The question is how well equipped the majority of people are to cope/confront without knowing everything that we know. I think a big part of vision 2020 is becoming the first provider people will turn to with these issues, even if it’s just for education, as they don’t really get a whole lot from most physicians.
I had an eval today with a guy with LBP/radic signs. He had min decreased sensation and strength in his S1 dermatome/myotome and very low irritability of his low back. His surgeon told him that it will probably go away but that he “can surgery if he wants to”. Half the eval was spent on education, because he now thinks he needs to get surgery. Even in those cases that will get better without hands on treatment, I think there would be value in having people come in even if it’s for assessment (including functional and psychosocial outcome measures, yellow flags etc.) and education only.
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