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Low Back Pain & Timing of Referrals
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The consensus on when to refer to physical therapy for non-specific low back pain (LBP) is in a state of transition. A study published in Spine last December reviewed the medical records of 32,070 patients with a new, primary care LBP consultation.1 They found that the median time from primary care consult to first physical therapy visit was 14 days, with 53% of physical therapy episodes starting within 14 days and 47% of episodes starting later. Those patients who started physical therapy earlier showed statistically significant patterns toward improved outcomes and lower costs.

For decades, the dominant philosophy was that low back pain was a self-limiting injury that healed on its own in the majority of cases.2 This thinking led to a popular recommendation that physical therapy should be withheld for one to three months.3-5

Our current knowledge of low back pain has transitioned to the concept that LBP is no more an injury than a heart attack is an injury. Rather, acute low back pain announces a disease process more akin to a deconditioning syndrome.6 We now understand that the majority of LBP healthcare costs stem from re-use of the system. Therefore, the singular report of “recovery” that undergirded the old delayed-referral recommendation is now understood to be insufficient. To control healthcare costs and protect patients, future and potentially worse LBP events must be avoided.

The 2005 estimate for annual, direct healthcare costs related to LBP is $85 billion – up 65% from 1997.7 Most patients first take their LBP complaints to a primary care practitioner, putting primary care in the driver’s seat for controlling healthcare costs and influencing patient outcomes.8

In the current study, Fritz and colleagues extracted data from a national database of employer-sponsored health plans. Reviewing the billing records of 32,070 LBP patients, they found that starting PT within 14 days of the primary care consult correlated with numerous advantages compared to later referrals:

  • Medical costs reduced by $2,736 per patient
  • Use of advanced imaging reduced by 74%
  • Need for surgery reduced by 55%

These results are consistent with a similar study analyzing Medicare billing records,8 suggesting that early
referral proves beneficial for both working-age patients and retirees.

The take-away for our referring practitioners is that the old idea of delaying physical therapy to control costs has proven counterproductive. Research demonstrates that costs are contained better when the physical therapy referral is made as soon as possible – even during the acute phase.

References:

1. Fritz J, Childs J, Wainner R, Flynn T. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012; 37 (25): 2114-21.

2. Nelson Brian W. A rational approach to the treatment of low back pain. The Journal of Musculoskeletal Medicine 1993; May: 67-82.

3. Koes B, van Tulder M, Lin CC, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19: 2075-94.

4. Murphy A, van Teijlingen E, Boggi M. Inconsistent grading of evidence across countries: a review of low back pain guidelines. J Manip Physiol Ther. 2006; 29: 576-81.

5. Moffett J, McLean S. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatol. 2006; 45: 371-8.

6. Carpenter David M, Brian W Nelson: Low back strengthening for the prevention and treatment of low back pain. Medicine & Science in Sports & Exercise 1999 Vol 1 No 31; pp 18-24.

7. Martin B, Deyo R, Mirza S, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008; 299: 656-64.

8. Gelhorn A, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine. 2012; 37 (9): 775-782.

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For Your Health,

Dr. Ryan Moorman

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