The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review

Time to Service and Its Relationship with Outcomes in Workers with Compensated Musculoskeletal Conditions: A Scoping Review

PURPOSE

A comprehensive review of the literature on the time between the onset of symptoms and the first episode of care and its effects on important worker outcomes in compensated musculoskeletal conditions is currently lacking. This scoping review aimed to summarize the factors associated with time to service and describe outcomes in workers with workers' compensation accepted claims for musculoskeletal conditions.

METHODS

We used the JBI guidelines for scoping reviews and reported following the PRISMA-ScR protocol. We included peer-reviewed articles published in English that measured the timing of health service initiation. We conducted searches in six databases, including Medline (Ovid), Embase (Ovid), PsycINFO, Cinahl Plus (EBSCOhost), Scopus, and the Web of Science. Peer-reviewed articles published up to November 01, 2022 were included. The evidence was summarized using a narrative synthesis.

RESULTS

Out of the 3502 studies identified, 31 were included. Eight studies reported the factors associated with time to service. Male workers, availability of return to work programmes, physically demanding occupations, and greater injury severity were associated with a shorter time to service, whereas female workers, a high number of employees in the workplace, and having legal representation were associated with a longer time to service. The relationship between time service and worker outcomes was observed in 25 studies, with early access to physical therapy and biopsychosocial interventions indicating favourable outcomes. Conversely, early opioids, and MRI in the absence of severe underlying conditions were associated with a longer duration of disability, higher claim costs, and increased healthcare utilization.

CONCLUSION

Existing evidence suggests that the time to service for individuals with compensated musculoskeletal conditions was found to be associated with several characteristics. The relationship between time to service and worker outcomes was consistently indicated in the majority of the studies. This review highlights the need to consider patient-centred treatments and develop strategies to decrease early services with negative effects and increase access to early services with better outcomes.

Informing low back pain care from the ground up: Survey of national musculoskeletal triage physiotherapists in Ireland

BACKGROUND

Healthcare is changing to meet the challenge of a rising musculoskeletal burden associated with the expanding, aging population. Clinicians, important stakeholders in healthcare provision, have crucial insights into service improvement, but clinician consultation is a shortcoming in healthcare development. In Ireland, specialist physiotherapist-led musculoskeletal (MSK) triage services operate at the primary-secondary care interface to expedite patient care.

OBJECTIVES

To inform future development of low back pain (LBP) care in Ireland through profiling the operationalisation of the national MSK triage service for LBP, including access, referral management, clinical investigations, onward referral options, access to multidisciplinary team (MDT) services and integration with primary healthcare services.

DESIGN

Cross-sectional observational study using a bespoke, anonymous electronic survey.

PARTICIPANTS

Thirty-eight clinical specialist physiotherapists working in national programme Irish MSK triage services.

RESULTS

Thirty-eight MSK Triage physiotherapists submitted responses (response rate 72%). There was considerable site-dependent variation in LBP service provision, with discrepancies in access to triage services, wait times, referral processing and prioritisation, access to clinical investigations and onward referral options. Most respondents (81%) reported wait times exceeding the three-month target; 75% reported that the level of clinical autonomy associated with their role limited service efficiency; 75% were dissatisfied with primary-secondary care service integration. Respondents identified insufficient availability of primary care multidisciplinary services.

CONCLUSION

Lack of standardisation of LBP services exists in Ireland. Services would benefit from improved standardisation, reduced wait times, national accreditation and a defined scope of advanced physiotherapy practice and the development of nationwide community multidisciplinary infrastructure with enhanced interservice communication.

Orthopaedic Manual Physical Therapy: A Modern Definition and Description

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Physical therapy in the Emergency Department: A prospective cohort study from an Alternatives to Opioids program

Objective

Musculoskeletal pain complaints are common in the emergency department (ED). The objective of this study was to determine the impact of physical therapy (PT) in the ED on pain and ED return.

Methods

A prospective cohort study was performed with those presenting to the ED or Urgent Care at a single academic center for musculoskeletal pain between November 2020 and December 2022. All patients were referred to outpatient PT. During business hours, PT was available to begin treatment in the ED. Long-term follow-up was performed using the electronic health records. Statistical analyses included descriptive and non-parametric pairwise comparisons, Fisher's exact test, and multiple logistic regression.

Results

A total of 974 patients were included in the study with 553 completing optional surveys. Back pain was most common. Pain was reduced at ED discharge for all patients, but pain was significantly improved if patients saw PT in the ED. Patients in the ED were less likely to keep their outpatient PT appointments than others, but importantly, patients who saw PT in the ED were less likely to return to the ED for the same complaint up to 1 year later. Those who kept PT appointments were likely to establish or maintain healthcare outside emergency services later.

Conclusions

Initiating PT in this ED reduces pain at ED discharge. However, patients who utilized PT were more likely to later utilize health care resources outside of emergency services. Those who saw PT in this ED were less likely to return to the ED for the same complaint up to 1 year later.

Getting what you pay for: impact of copayments on physical therapy and opioid initiation, timing, and continuation for newly diagnosed low back pain

BACKGROUND CONTEXT

Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common.

PURPOSE

We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP.

STUDY DESIGN/SETTING

The IBM Watson Health MarketScan claims database was used in a longitudinal setting.

PATIENT SAMPLE

Adult patients with LBP.

OUTCOME MEASURES

The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing.

METHODS

Actual and inferred copayments based on nonnonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage.

RESULTS

Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50-74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75-100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887-0.899] and HR=0.905 [95%CI 0.899-0.912], respectively).

CONCLUSIONS

Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Copays may impact long-term adherence to PT.

On-Site Physiotherapy in Emergency Department Patients Presenting with Nonspecific Low Back Pain: A Randomized Controlled Trial

Background: There is a high incidence of nonspecific Low Back Pain (LBP) in patients visiting Emergency Departments (EDs), but there is a lack of knowledge regarding emergency physiotherapy for LBP. The effect of on-site physiotherapy in these patients was therefore never demonstrated. We assessed short-term outcomes, feasibility and patient satisfaction with physiotherapy in ED patients presenting with nonspecific LBP. Methods: A block-randomized, controlled, open-label trial with a follow-up of 42 days. Patients aged 18 years or older presenting to an ED with nonspecific LBP were prospectively enrolled. Both groups received the same booklet with written information on LBP management and exercises. Patients in the intervention group were given additional instructions by a certified physiotherapist. Results: We included 86 patients in the primary analysis. The median age was 40, and 40.7% were female. At day 7, the median Oswestry Disability Index (ODI) was 2 points lower in the intervention group compared to the control group, which was not statistically significant. There was no between-group difference in pain at day 7. Patients who received physiotherapy felt significantly more confident with the exercises they were taught (p = 0.004, effect size = 0.3 [95% CI 0.1 to 0.5]). Conclusions: On-site physiotherapy in ED patients presenting with nonspecific low back pain is associated with higher patient satisfaction, compared to standard of care. The effect of physiotherapy was small, with only minimal improvement in disability, but without a reduction in pain. Despite the very small effect size, physiotherapeutic interventions should be investigated in larger cohorts with an extended intervention including patient education, exercises, and other physiotherapeutic modalities.

Association between physiotherapy utilization and medical healthcare utilization and costs in adults with back pain from Ontario, Canada: a population-based cohort study

ABSTRACT

This study examined the association between physiotherapy utilization and subsequent medical healthcare utilization and costs in a population-based sample of adults with back pain in Ontario. We conducted a population-based cohort study of Ontario respondents with back pain (≥18 years) of the Canadian Community Health Survey 2003 to 2010 cycles, linked to health administrative data up to 2018. Physiotherapy utilization was defined as self-reported consultation with a physiotherapist in the past 12 months. A propensity score-matched cohort was conducted to match adults with and without physiotherapy utilization, accounting for potential confounders. We assessed associations using negative-binomial and linear (log-transformed) regression to evaluate outcomes of healthcare utilization (back pain-specific and all-cause) and costs, respectively, at 1- and 5-year follow-up. There were 4343 pairs of matched respondents. Compared with those who did not receive physiotherapy, adults who received physiotherapy were more likely to have back pain-specific physician visits (RR women (5years) = 1.48, 95% CI 1.24-1.75; RR men (5years) = 1.42, 95% CI 1.10-1.84). Women who received physiotherapy had 1.11 times the rate of all-cause physician visits (RR 1year = 1.11, 95% CI 1.02-1.20), and men who received physiotherapy had 0.84 times the rate of all-cause hospitalizations (RR 5years = 0.84, 95% CI 0.71-0.99) than those who did not. There was no association between physiotherapy utilization and healthcare costs. Adults with back pain who received physiotherapy are more likely to have back pain-specific physician visits up to 5-year follow-up than those who did not. Physiotherapy utilization is linked to some sex-based differences in all-cause healthcare utilization but not differences in costs. Findings inform interprofessional collaboration and allied healthcare delivery for back pain in Ontario.

Effect of physical therapy timing on patient-reported outcomes for individuals with acute low back pain: A systematic review with meta analysis of randomized controlled trials

OBJECTIVE

The purpose of this systematic review with meta-analysis was to investigate the effect of early physical therapy (PT) for the management of acute low back pain (LBP) on patient-reported outcomes of pain and disability, compared to delayed PT or non-PT care.

LITERATURE SURVEY

Randomized controlled trials in three electronic databases (MEDLINE, CINAHL, Embase) were searched from inception to June 12, 2020, and updated on September 23, 2021.

METHODOLOGY

Eligible participants were individuals with acute low back pain. The intervention was early PT compared to delayed PT or non-PT care. Primary outcomes included the patient-reported outcomes of pain and disability. The following information was extracted from included articles: demographic data, sample size, selection criteria, PT interventions, and pain and disability outcomes. Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale. Random effects models were used for the meta-analysis.

SYNTHESIS

Seven of 391 articles met the eligibility criteria and were included in the meta-analysis. Random effects meta-analysis comparing early PT to non-PT care for acute LBP indicated a significant reduction in pain (standard mean difference [SMD] = 0.43, 95% confidence interval [CI]: -0.69 to -0.17) and disability (SMD = 0.36, 95% CI: -0.57 to -0.16) in the short term. Early PT compared to delayed PT did not result in improvement in short-term pain (SMD = -0.24, 95% CI: -0.52 to 0.04) or disability (SMD = 0.28, 95% CI: -0.56 to 0.01), or long-term pain (SMD = 0.21, 95% CI: -0.15 to 0.57) or disability (SMD = 0.14, 95% CI: -0.15 to 0.42).

CONCLUSIONS

This systematic review and meta-analysis suggest early PT versus non-PT care is associated with statistically significant reductions in short-term pain and disability (up to 6 weeks) with small effect sizes. The results indicate a nonsignificant trend favoring a small benefit of early PT over delayed PT for outcomes at short-term follow-up but no effect at long-term follow-up (6 months or greater).

Nonopioid pharmacological management of acute low back pain: A level I of evidence systematic review

Acute low back pain (LBP) imposes a significant socioeconomical burden as it is the condition that, worldwide, cause the most disability. Nonetheless, the literature regarding the best pharmacological management of acute LBP is limited, and the indications available in the literature are conflicting. This work investigates whether the pharmacological management of acute LBP can effectively reduce pain and disability, and aims to identify which drugs show the highest efficacy. This systematic review was conducted according to the 2020 PRISMA statement. In September 2022, PubMed, Scopus, and Web of Science were accessed. All the randomized controlled trials investigating the efficacy of myorelaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and paracetamol for acute LPB were accessed. Only studies that investigated the lumbar spine were included. Only studies reporting on patients with acute LBP with symptom duration of less than 12 weeks were included. Only patients older than 18 years and with nonspecific low back pain were included. Studies that investigated the use of opioids in acute LBP were not considered. Data from 18 studies and 3478 patients were available. Myorelaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately one week. The combination of NSAIDs and paracetamol was associated with a greater improvement than the use of NSAIDs alone, but paracetamol alone did not induce any significant improvement. Placebo was not effective in reducing pain. Clinical Significance: Myorelaxants, NSAIDs, and NSAIDs with paracetamol could reduce pain and disability in patients with acute LBP.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review

OBJECTIVE

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).

METHODS

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

RESULTS

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

CONCLUSIONS

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings.

IMPACT

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems.

LAY SUMMARY

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.

The Effects of Early Physiotherapy Treatment on Musculoskeletal Injury Outcomes in Military Personnel: A Narrative Review

The risks and incidence rates of musculoskeletal injuries among military personnel are high, and the importance of physiotherapy in treating these injuries is well established. However, what is less clear is whether the timing of commencement of physiotherapy treatment affects musculoskeletal injury outcomes in military personnel. This lack of clarity is exacerbated by the known underreporting of injuries among military personnel, and the resulting self-management of musculoskeletal injuries using analgesics, non-steroidal anti-inflammatories and other means. This narrative review was designed to identify and synthesize current evidence regarding the effects of timing of physiotherapy treatment on musculoskeletal injury outcomes, focusing on potential benefits of early versus typical or delayed commencement of physiotherapy treatment. Overall, current evidence suggests early physiotherapy treatment of musculoskeletal injuries offers distinct advantages over typical or delayed commencement of physiotherapy treatment in military settings. Specifically, it appears early treatment expedites recovery in early phases following injury onset and benefits longer term mental health and well-being. It may also reduce the need for more invasive and costly health care interventions and enable earlier return to training and operational service. Importantly, a cultural shift within military contexts to ensure early reporting of musculoskeletal injuries is required if the benefits of early commencement of physiotherapy treatment are to be achieved.

Disparities Exist in Physical Therapy Utilization and Time to Utilization Between Black and White Patients With Musculoskeletal Pain

OBJECTIVE

Black patients are less likely than White patients to receive physical therapy for musculoskeletal pain conditions. Current evidence, however, is limited to self-reported conditions and health services use. The purpose of this study was to use a large electronic health record database to determine whether a race disparity existed in use of physical therapy within 90 days of a new musculoskeletal diagnosis.

METHODS

Eligible patients (n = 52,384) were sampled from an Optum deidentified electronic health record database of 5 million adults distributed throughout the United States. In this database, patients were designated as "Black" and "White." Patients were eligible if they had a new diagnosis for musculoskeletal neck, shoulder, back, or knee pain between January 1, 2012, and December 31, 2017. Logistic regression and Cox proportional hazard models were computed before and after adjusting for covariates to estimate the association between race and receipt of physical therapy services within 90 days of musculoskeletal pain diagnoses.

RESULTS

Patients were on average 47.5 (SD = 14.9) years of age, 12.8% were Black, 87.2% were White, and 52.7% were female. Ten percent of Black patients and 15.5% of White patients received physical therapy services within 90 days of musculoskeletal pain diagnoses. After adjusting for covariates, White patients were 57% more likely (odds ratio = 1.57; 95% CI = 1.44-1.71) to receive physical therapy compared with Black patients and had significantly shorter time to physical therapy than Black patients (hazard ratio = 1.53; 95% CI = 1.42-1.66).

CONCLUSIONS

In a nationally distributed cohort, Black patients were less likely than White patients to utilize physical therapy and had a longer time to utilization of physical therapy for musculoskeletal pain.

IMPACT

These findings highlight the need to determine the mechanisms underlying the observed disparities and how these disparities influence health outcomes.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database

Background

Early initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending.

Methods

Using the Truven MarketScan database, we identified nearly 980,000 US adults ages 18–64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05.

Results

At 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40–0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47–0.51), emergency department visits (OR = 0.51, 95% CI = 0.49–0.54), advanced imaging (OR = 0.57, 95% CI = 0.56–0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66–0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65–0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4–25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to −$410; P < 0.001).

Conclusion

Early PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08255-0.

Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic

INTRODUCTION

Spine pain is one of the largest and costliest burdens to our healthcare systems. While evidence-based guidelines for spine pain have been established, and continue to evolve, the actual management of this condition continues to burden the healthcare system. This has led to increased costs due to inefficient entry to healthcare, utilization of treatments unsupported by clinical guidelines, and patient navigation through our healthcare systems. The purpose of this study was to assess the healthcare utilization and related outcomes for Active Duty Service Members (ADSM) receiving healthcare services in a novel acute spine pain clinic (ASPC) during the first 5 years of operation at a large Military Treatment Facility.

MATERIALS AND METHODS

In 2014 the Physical Medicine and Rehabilitation and Physical Therapy (PT) services designed a novel acute spine clinic intended to directly receive ADSM with acute spine symptoms for an initial evaluation by a Physical Therapist. The inclusion criteria into the ASPC were: ADSM, pain less than or equal to 7 days, no more than three prior episodes of acute spine pain in the past 3 years, and not currently receiving care from Chiropractic, Pain Management, or PT services. The exclusion criteria were: significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma.

RESULTS

A total of 1,215 patients presented to the ASPC for evaluation between 2014 and 2019. The most common chief complaint was acute pain in the lumbar spine (73%), followed by cervical spine pain (15%), and thoracic spine pain (12%) represented the fewest. The average number of PT visits per patient was 3.5 (range 1-13) with 61.1% utilizing three or fewer visits. Over 95% of cases returned to work the same day as their initial evaluation. Sixty-six percent returned to work without restriction the same day as their initial evaluation. Light duty recommendations were provided to 412 (33.9%) patients ranging from one to 30 days, with greater than 85% of the light duty being less than 14 days. Recommendations to not return to work (sick-in-quarters) were issued to 56 (4.6%) patients. The sick-in-quarters recommendations were for a 24-hour period in 48 cases, 48 hours for seven cases, and 72 hours for one case. All encounters in which the patient first sought care at the ASPC for low back pain met the Healthcare Effectiveness Data Set standard for low back pain care of having no imaging within 28 days of the first encounter for nonspecific low back pain. A medical record review of 100 randomly selected patients within 12 months of the initial evaluation demonstrated decreased utilization of medication, imaging, and referral to surgical services.

CONCLUSIONS

This innovative approach demonstrates the potential benefits of rapid access to treatment and education for patients with acute spine pain by a Physical Therapist. Modeling this approach at Military Treatment Facilities may lead to decreased utilization of medications, radiology services, specialty care referrals, and reduced cost of care provided to individuals with acute spine pain.

Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System

OBJECTIVE

To investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and ankle-related medical care use at 1 year after ankle sprain.

DESIGN

Retrospective cohort study of all beneficiaries of the US Military Health System seeking care for an ankle sprain over a 4-year period.

METHODS

Individuals were classified according to whether they did or did not receive physical rehabilitation. For those who received rehabilitation (n = 6150), linear relationships (with appropriate covariate controls) were analyzed with generalized linear models and generalized additive models to measure the effects of rehabilitation timing on injury recurrence and injury-related medical care use (costs and visits) at 1 year after injury. The nonlinear effect of rehabilitation timing on the probability of recurrence was assessed.

RESULTS

Approximately 1 in 4 people received rehabilitation. The probability of ankle sprain recurrence increased for each day that rehabilitation was not provided during the first week. The probability of ankle sprain recurrence plateaued until about 2 months after initial injury, then increased again, with 2 times greater odds of recurrence compared to those who received physical rehabilitation within the first month. When rehabilitation care was delayed, recurrence (odds ratio [OR] = 1.28), number of foot/ankle-related visits (OR = 1.22), and foot/ankle-related costs increased (OR = 1.13; up to $1400 per episode).

CONCLUSION

The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred. J Orthop Sports Phys Ther 2021;51(12):619-627. doi:10.2519/jospt.2021.10730.

The impact of graft type on rehabilitation outcomes following ACL reconstruction: Bone patellar tendon bone versus quadriceps tendon grafts

OBJECTIVE

The aims of this study were to 1) compare the dosage of physical therapy provided for patients following an anterior cruciate ligament reconstruction (ACL-R) with either quadriceps or bone-patellar tendon-bone (BPTB) graft type and their resulting outcomes and 2) investigate the frequency therapists documented surgical graft type.

DESIGN

Retrospective observational.

SETTING

Outpatient orthopedics.

PARTICIPANTS

Data was collected from the electronic medical records of 212 patients: BPTB (41) and quadriceps tendon (33) were analyzed. Forty-eight cases were other graft types and 90 were unspecified.

MAIN OUTCOME MEASURE

An independent samples t-test was used to compare differences in knee range of motion (ROM) and Knee Functional Status (FS) between BPTB and quadriceps grafts.

RESULTS

There were no differences in knee flexion (p = 0.148) or extension (p = 0.305) ROM between groups at discharge. The quadriceps group achieved greater improvement in functional outcomes (p < 0.001). The quadriceps group received more sessions (p = 0.021) and a longer duration of care (p = 0.007).

CONCLUSIONS

The significant difference in treatment dosage makes it difficult to conclude which graft is superior. It is unknown if the frequent omission of graft type in the patient chart is an indication of poor documentation practice or a lack of perceived importance in knowing the graft type for PT.

Changes in Pain Catastrophizing and Fear-Avoidance Beliefs as Mediators of Early Physical Therapy on Disability and Pain in Acute Low-Back Pain: A Secondary Analysis of a Clinical Trial

OBJECTIVE

The Fear-Avoidance Model of chronic pain (FAM) posits that pain catastrophizing and fear-avoidance beliefs are prognostic for disability and chronicity. In acute low-back pain, early physical therapy (PT) is effective in reducing disability in some patients. How early PT impacts short- and long-term changes in disability for patients with acute pain is unknown. Based on the FAM, we hypothesized that early reductions in pain catastrophizing and fear-avoidance beliefs would mediate early PT's effect on changes in disability (primary outcome) and pain intensity (secondary outcome) over 3 months and 1 year.

SUBJECTS

Participants were 204 patients with low-back pain of < 16 days duration, who enrolled in a clinical trial (NCT01726803) comparing early PT sessions or usual care provided over 4 weeks.

METHODS

Patients completed the Pain Catastrophizing Scale (PCS), Fear-Avoidance Beliefs Questionnaire (FABQ work and physical activity scales) and outcomes (Oswestry Disability Index and Numeric Pain Rating Scale) at baseline, 4 weeks, 3 months, and 1 year. We applied longitudinal mediation analysis with single and multiple mediators.

RESULTS

Early PT led to improvements in disability and pain over 3 months, but not 1 year. In the single mediator model, four-week reductions in pain catastrophizing mediated early PT's effects on 3-month disability and pain intensity improvements, explaining 16% and 22% of the association, respectively, but the effects were small. Pain catastrophizing and fear-avoidance beliefs did not jointly mediate these associations.

CONCLUSIONS

In acute low-back pain, early PT may improve disability and pain outcomes at least partly through reducing patients' catastrophizing.

Uncovering inefficiencies in the workers’ compensation industry using Lean methodology

Purpose

The purpose of this paper is to apply Lean in the workers’ compensation industry. It focuses on identifying patterns of repetitive non-value-added transnational activities for physical-therapy patients and healthcare providers. It addresses the research gap in this field.

Design/methodology/approach

In this study, we designed and deployed multiple case studies to better understand the journey of an injured worker within the worker compensation system in the United States of America. We partnered with Concentra Inc., a leading national healthcare provider in the field of workers’ compensation having 520 medical centers in 44 states. Both case studies included conducting direct observations, Gemba walk, in five clinics in two states: Florida and Pennsylvania. We analyzed the data of 263 injured workers with 8 or more physical therapy visits who got admitted to Concentra clinics in both states over the period of 31 days.

Findings

The results revealed that the time intervals at which activities associated with physical therapy treatment pre-authorization accounted for 91.59% of the total non-value-added activities and are thus the key administrative factor leading to process inefficiency in the state of Florida. The Process Cycle Efficiency of Pennsylvania was 75.36% compared to 53.16% of Florida. The injured workers in Florida needed 39.58 days on average to complete eight physical therapy visits compared to 27.92 days in Pennsylvania (a median of 34.09 vs 22.15 days).

Research limitations/implications

This study is limited as it only focuses on processes on the healthcare provider side. An expanded value stream map that includes the treatment pre-authorization process on the insurance side would be beneficial for generating more potential solutions to streamline the process.

Practical implications

This study shows that Lean could play a critical role in identifying and quantifying continuous improvement opportunities that could accelerate patient’s treatment, reduce administrative burden on healthcare providers and improve the overall claim cost of insurance companies. It provides data-driven argument for insurance companies to consider eliminating physical therapy pre-authorization.

Originality/value

This is the first study to apply Lean methodology in the workers’ compensation field.

Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study

Background

Early physical therapy has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions, but it has not been investigated in individuals with patellofemoral pain. The purpose was to evaluate how the use and timing of physical therapy influenced downstream healthcare use, costs, and recurrence rates.

Methods

Seventy-four thousand four hundred eight individuals aged 18 to 50 diagnosed with patellofemoral pain between 2010 and 2011 in the Military Health System were categorized based on use and timing of physical therapy (first, early, or delayed). Healthcare use, costs, and recurrence rates were compared between the groups using descriptive statistics and a binary logit regression.

Results

The odds for receiving downstream healthcare use (i.e. imaging, prescription medications, and injections) were lowest in those who saw a physical therapist as the initial contact provider (physical therapy first), and highest in those who had delayed physical therapy (31–90 days after patellofemoral pain diagnosis). Knee-related costs for those receiving physical therapy were lowest in the physical therapy first group ($1,136, 95% CI $1,056, $1,217) and highest in the delayed physical therapy group ($2,283, 95% CI $2,192, $2,374). Recurrence rates were lowest in the physical therapy first group (AOR = 0.55, 95% CI 0.37, 0.79) and highest in the delayed physical therapy group (AOR = 1.78, 95% CI 1.36, 2.33).

Conclusions

For individuals with patellofemoral pain using physical therapy, timing is likely to influence outcomes. Healthcare use and costs and the odds of having a recurrence of knee pain were lower for patients who had physical therapy first or early compared to having delayed physical therapy.

The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain

BACKGROUND

Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs.

OBJECTIVE

To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence.

STUDY DESIGN

Retrospective cohort.

SETTING

United States Military Health System civilian and military clinics.

PATIENTS

23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy.

INTERVENTIONS

Physical therapy provided to individuals who did or did not receive an initial radiograph.

MAIN OUTCOME MEASURES

Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs).

RESULTS

If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22).

CONCLUSIONS

Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.

Experiences of Nonpharmacologic Providers Implementing the Oregon Back Pain Policy Expanding Services for Medicaid Recipients: A Focus Group Study

Introduction: The objective of this study was to understand the experiences of nonpharmacologic therapy (NPT) providers implementing the Oregon Back Pain Policy (OBPP). The Medicaid OBPP expanded coverage of evidence-based NPTs for back pain and simultaneously restricted access to acute and chronic opioid therapy and some interventional approaches for chronic back pain. Materials and Methods: This study uses a cross-sectional, observational design. The authors conducted three online focus groups with 44 credentialed NPT providers in February 2020. Qualitative data analysis was conducted by a multidisciplinary team with an immersion/crystallization approach. Results: Four themes emerged from the data. Participants reported: (1) a lack of direct communication about the policy and mixed levels of understanding of the policy, (2) belief that expanding access to NPT and restricting opioids was beneficial for patients, (3) implementation challenges that compromised access and the perceived effectiveness of care, and (4) financial challenges in accepting Medicaid referrals, due to reimbursement and administrative burden. Conclusion: The goal of the OBPP was to increase access to evidence-based back pain care, including new coverage of NPT services and decreased opioid prescribing for back pain. This study revealed that although many NPT providers support the goals of this policy, the policy was not communicated systematically to providers and was hampered by implementation challenges.

Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis

BACKGROUND

Musculoskeletal conditions are common and cause high levels of disability and costs. Physical therapy is recommended for many musculoskeletal conditions. Past research suggests that referral rates appear to have increased over time, but the rate of accessing a physical therapist appears unchanged.

OBJECTIVE

Our retrospective cohort study describes the rate of physical therapy use after referral for a variety of musculoskeletal diagnoses while comparing users and non-users of physical therapy services after referral.

METHODS

The study sample included patients in the University of Utah Health system who received care from a medical provider for a musculoskeletal condition. We included a comprehensive set of variables available in the electronic data warehouse possibly associated with attending physical therapy. Our primary analysis compared differences in patient factors between physical therapy users and non-users using Poisson regression.

RESULTS

15 877 (16%) patients had a referral to physical therapy, and 3812 (24%) of these patients accessed physical therapy after referral. Most of the factors included in the model were associated with physical therapy use except for sex and number of comorbidities. The receiver operating characteristic curve was 0.63 suggesting poor predictability of the model but it is likely related to the heterogeneity of the sample.

CONCLUSIONS

We found that obesity, ethnicity, public insurance and urgent care referrals were associated with poor adherence to physical therapy referral. However, the limited predictive power of our model suggests a need for a deeper examination into factors that influence patients access to a physical therapist.

Clinical guidelines and care pathway for management of low back pain with or without radicular pain

OBJECTIVE

To develop guidelines for low back pain management according to previous international guidelines and the updated literature.

METHODS

A report was compiled from a review of systematic reviews of guidelines published between 2013 and 2018 and meta-analysis of the management of low back pain published between 2015 and 2018. This report summarized the state-of-the-art scientific knowledge for each predefined area of the guidelines from a critical review of selected literature. A multidisciplinary panel of experts including 17 health professionals involved in low back pain management and 2 patient representatives formulated preliminary guidelines based on the compilation report and a care pathway. The compilation report and preliminary guidelines were submitted to 25 academic institutions and stakeholders for the consultation phase. From responses of academic institutions and stakeholders, the final guidelines were developed. For each area of the guidelines, agreement between experts was assessed by the RAND/UCLA method.

RESULTS

The expert panel drafted 32 preliminary recommendations including a care pathway, which was amended after academic institution and stakeholder consultation. The consensus of the multidisciplinary expert panel was assessed for each final guideline: 32 recommendations were assessed as appropriate; none was assessed as uncertain or inappropriate. Strong approval was obtained for 27 recommendations and weak for 5.

CONCLUSION

These new guidelines introduce several concepts, including the need to early identify low back pain at risk of chronicity to provide quicker intensive and multidisciplinary management if necessary.

Providing value-based care as a physiotherapist

Background

Despite millions spent in research funding, studies, and guidelines, outcomes involving musculoskeletal care continue to decline. The purpose of this Viewpoint is to describe value-based care and to suggest measures for its adoption by physiotherapists who manage individuals with musculoskeletal related pain disorders.

Discussion

The provision of value-based care is best defined as care that includes: 1) patient centeredness, 2) guideline-oriented, integrated strategies, 3) measurement of patient outcomes and experiences, and 4) cost effectiveness. Physiotherapists are well positioned to be leaders in the application of value-based care by assuring they address each of the four strategies during the daily patient encounter. This Viewpoint discusses strategies for application to clinical practice.

Conclusion

By implementing value-based care principals, physiotherapists could assure that patients with musculoskeletal related pain disorders receive the right care at the right time, by the right provider.

A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain

OBJECTIVE

Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain.

METHODS

This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models.

RESULTS

For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]).

CONCLUSION

In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored.

IMPACT

ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes.

LAY SUMMARY

Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.

Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial

BACKGROUND

Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems.

DESIGN

The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss).

SUMMARY

The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

'You’re the best liar in the world’: a grounded theory study of rowing athletes’ experience of low back pain

Objectives

Low back pain (LBP) is common in rowers and leads to considerable disability and even retirement. The athlete voice can help clinicians to better understand sport-related pain disorders. We aimed to capture the lived experience of LBP in rowers.

Methods

Cross-sectional qualitative study using a grounded theory approach. Adult competitive rowers with a rowing-related LBP history were recruited in Australia and Ireland. Data were collected through interviews that explored: context around the time of onset of their LBP and their subsequent journey, experiences of management/treatment, perspectives around present beliefs, fears, barriers and expectations for the future.

Results

The 25 rowers (12 women/13 men) who participated were aged 18–50 years; they had a mean 12.1 years of rowing experience. They discussed a culture of concealment of pain from coaches and teammates, and fear of being judged as ‘weak’ because of the limitations caused by LBP. They reported fear and isolation as a result of their pain. They felt that the culture within rowing supported this. They reported inconsistent messages regarding management from medical staff. Some rowers reported being in a system where openness was encouraged—they regarded this a leading to better outcomes and influencing their LBP experience.

Conclusions

Rowers’ lived experience of LBP was influenced by a pervasive culture of secrecy around symptoms. Rowers and support staff should be educated regarding the benefits of early disclosure and rowers should be supported to do so without judgement.

Physical therapy and opioid use for musculoskeletal pain management: competitors or companions?

Existing evidence is reviewed and gaps in the literature are identified to better understand how physical therapy has been used to provide exposure to nonpharmacological treatments.

Musculoskeletal (MSK) pain conditions are highly prevalent and a leading cause of disability globally. When people with MSK pain seek health care, they often receive treatment not aligned with best practices, including initial management options such as opioids. In recent practice guidelines, nonpharmacological treatments have been emphasized for initial pain management, and physical therapists are providers who routinely deliver nonpharmacological treatments. The purpose of this review is to describe the current and future state for how physical therapy may be used to increase exposure to nonpharmacological treatments for MSK pain conditions. For the current state, we review existing observational evidence investigating early exposure to physical therapy and its influence on subsequent opioid use. For the future state, we propose clinical research questions that could define the role of physical therapy on interdisciplinary teams working towards improving effectiveness of nonpharmacological treatments through more rigorous study designs. These clinical questions are intended to guide health services research and clinical trials when building an evidence base of nonpharmacological care options for MSK pain conditions.

Fluoroscopic Epidural Steroid Injection: Pain Relief in Discogenic Sciatica Versus Lumbar Spinal Stenosis. A Study on Middle Eastern Patients

OBJECTIVE

To compare the effect of epidural steroid injections (ESI) in patients with discogenic sciatica (Sci) versus patients with lumbar canal stenosis (LSS), not controlled by conservative treatment.

MATERIALS AND METHODS

In our study, 80 patients with Sci and 66 with LSS were included. A single ESI (10 mg dexamethasone in 3 cc 0.25% bupivacaine) was applied under fluoroscopic control: one level above the highest stenotic level, in the posterior epidural space, via interlaminar approach in LSS and at the prolapse level, in the anterior epidural space, via transforaminal route in Sci. Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention.

RESULTS

The procedure was successful in 78 Sci and 63 LSS patients. Patients with Sci responded significantly better. At one month, pain reduction over 50% was achieved in 63% (52.3-73.7% at p = 0.95) of Sci but only in 35% (23.2-46.8%) of LSS (p = 0.03). Return to pre-intervention level happened in 47% (34.7-59.3%) of LSS versus 14% (6.3-21.7%) of Sci patients (p = 0.01). In 5 patients the procedure failed, without resulting morbidity.

CONCLUSION

ESI are more effective in patients with Sci than in single level LSS. In multiple level LSS, results are disappointing.

Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs

OBJECTIVE

The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs.

METHODS

This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12 months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit.

RESULTS

Compared with the delayed physical therapy group (n = 94), the early physical therapy group (n = 171) had a lower risk of receiving lumbar surgery (relative risk [RR] = 0.47, 95% CI = 0.26-0.86) and advanced imaging (RR = 0.72, 95% CI = 0.55-0.95), and they were less likely to have long-term opioid use (RR = 0.45, 95% CI = 0.28-0.76). The early physical therapy group incurred lower costs (mean = $3,806, 95% CI = $1,998-$4,184) than those in the delayed physical therapy group (mean = $8,689, 95% CI = $4,653-$12,727).

CONCLUSION

Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12 months following the ED visit.

IMPACT STATEMENT

The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Utilization of Health Care Resources by Long-term Care Residents as a Function of Pain Status

OBJECTIVE

We estimated the association between the presence of pain and health care utilization among older adults residing in long-term care (LTC) facilities.

MATERIALS AND METHODS

Using administrative health data maintained by the Saskatchewan ministry of health and time-to-event analyses with multivariable frailty models, we tested for differences in health care use (hospitalization, physician and specialist visits, and prescription drug dispensations) as a function of pain status among LTC residents after admission to an LTC. Specifically, we contrasted LTC residents with daily pain or less than daily pain but with moderate or severe intensity (ie, clinically significant pain group; CSP) to residents with no pain or nondaily mild pain (NP/NDMP group).

RESULTS

Our cohort consisted of 24,870 Saskatchewan LTC residents between 2004 and 2015 with an average age of 85 years (63.2% female; 63.0% in urban facilities). Roughly one third had CSP at their LTC admission date. Health care use after admission to LTC was strongly associated with pain status, even after adjusting for residents' demographic and facility characteristics, prior comorbidities and health care utilization 1 year before the study index date. In any given quarter, compared with NP/NDMP residents, those with CSP had an increased risk of hospitalization, specialist visit, follow-up general practitioner visit, and onset of polypharmacy (ie, 3 or more medication classes).

DISCUSSION

To our knowledge, this is the first large-scale project to examine the utilization of health care resources as a function of pain status among LTC facility residents. Improved pain management in LTC facilities could lead to reduced health care use.