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Feb15th 2013

According to this new study from the University of Utah, early referral to physical therapy for mechanical low back pain is linked with: 1) lower overall health care costs, 2) fewer doctor visits, 3) less use of advanced imaging (CT scans, MRIs), 4) reduced risk of surgery and injections, and 5) decreased use of narcotic (opioid) medications.

The study was done by reviewing patient records from a national database of employer-sponsored health plans. Although the study was conducted by physical therapists, they had no influence on who among the 32,070 patients studied was sent to physical therapy (PT). They were just reporting trends observed from analyzing the data.

Of the 32,070 patients who were diagnosed with low back pain as the main complaint, seven percent were referred to PT. About 1100 patients received early PT (within 14 days of their doctor visit). The remaining 975 patients were categorized as delayed PT. They were sent to PT between 15 and 90 days after the primary care index (first) visit.

To get a better sense of national trends, the researchers analyzed characteristics of the individual patients. They looked at age, sex (male or female), and copayment for the first medical visit for low back pain. They also compared insurance plans (PPO, HMO, POS, HDHP, other), employment status, and geographic area where the patients lived. PPO stands for preferred provider organization. HMO is a health maintenance organization. POS is point-of-service and HDHP refers to high-deductible health plan.

What they found was if you live in the Northeast or West (United States), are covered by a preferred provider plan, and not taking narcotic medications, then you would be more likely to see a physical therapist early in the episode of your back pain. With early PT, you would be less likely to have surgery or injections and the cost savings would be nearly $3,000.00.

A second feature of the study was to compare cost savings for patients depending on how they were treated. There are Clinical Practice Guidelines (CPGs) based on research evidence that dictates how patients with mechanical low back pain should be treated. Health care providers who follow those guidelines (guided exercise and self-management) were referred to as adherent.

The second category (nonadherent) described patients who received care outside the guidelines such as hot packs, cold therapy, ultrasound. Costs associated with care according to the Guidelines were lower than nonadherent care. Each patient in the adherent group (treated according to the Guidelines) saved (on average) $1,374.00.

In summary, patients receiving early physical therapy for low back pain (within two-weeks of the episode) are less likely to need more invasive treatment with injections or surgery. Costs are less compared with patients referred later, especially if the treatment follows the current published Clinical Practice Guidelines. Type of health care provider/coverage is also a factor in who is referred to physical therapy for this problem (PPO referrals were greater than HMO).

The value of physical therapy in the treatment of low back pain remains an area of debate and study. This study did not examine which patients should be referred to physical therapy or the patient outcomes for those who were referred to early versus late. Further studies are needed to help determine who should be referred to and how soon after diagnosis.

Julie M. Fritz, PT, PhD, ATC, et al. Primary Care Referral of Patients with Low Back Pain to Physical Therapy. Impact on Future Health Care Utilization and Costs. In Spine. December 1, 2012. Vol. 37. No. 25. Pp. 2114-2121.