STUDY DESIGN: Randomized controlled trial.
OBJECTIVE: The aim of this study was to compare early physical therapy versus usual care in patients with low back pain.
SUMMARY OF BACKGROUND DATA: Early physical therapy (PT) has been associated with reduced downstream healthcare utilization in retrospective studies, but not investigated prospectively in the military health system.
METHODS: Military service members seeking care from a general practitioner were recruited. Patients attended a 20-minute self-management class with focus on psychosocial resilience and then randomized to usual care only (UC) versus immediately starting a 3-week physical therapy program (PT). Primary outcome was the Oswestry Disability Index at 1 year. Secondary outcomes included Oswestry scores at 4- and 12-week follow-up, numeric pain rating scale, global rating of change, and healthcare utilization at 1 year. Analysis of covariance was used to compare differences between groups, significance set at 0.05.
TRIAL REGISTRATION: clinicaltrials.gov: NCT01556581 RESULTS.: A total of 119 patients (mean age 27.2 years; mean BMI 27.8?kg/m; 15.1% female) enrolled (61 randomized to UC; 58 to PT). No between-group differences found on the Oswestry after 1 year. A between-group difference in Oswestry was present at 4 weeks (mean difference?=?4.4; 95% CI: 0.41-10.1; P?=?0.042) favoring PT. Total 1-year mean healthcare costs did not differ significantly between groups (UC $5037; 95 CI $4171-$6082 and PT $5299; 95 CI $4367-$6431). The portion of total mean healthcare costs related to low back pain was lower for UC ($1096; 95% CI $855-$1405) compared to PT ($2016, 95% CI $1570-$2590).
CONCLUSION: There was no difference between usual care and early PT after 1 year. PT provided greater improvement in disability after 4 weeks. As both groups improved, the impact of the education may have been underestimated. Patients in the PT group utilized greater back-pain-related healthcare resources, but overall healthcare costs did not differ compared to UC.
LEVEL OF EVIDENCE: 2.
|Rehab Clinician (OT/PT)|
Unfortunately, the study population (military service members) limits the applicability of the results to the general population. However, some strengths of the study include the follow-up period (1 year) and the tracking of health care costs between the two groups provides additional insight.
The findings of this study are inconsistent with others that find early physical therapy intervention associated with lower overall healthcare costs in the management of low back pain. An important role of the physical therapist is patient education; in this study both treatment groups received educational interventions. This should be considered, as the authors suggest, in interpreting the results.
Those of us who treat these patients continue to search for differences in outcome by testing various approaches to care, as we believe these differences must exist. The findings of this study did not capture these differences but the results are important for clinicians.
The apparent treatment of a condition with a multifactorial aetiology on the basis of the diagnostic label of a non-specific symptom remains as ever, problematic. The absence of blinding in the study design is also a concern. I am uncertain that this research actually tells us much that may be construed as meaningful.
This is a useful article for any clinician that works with lower back pain patients. One has to consider that the subject group is from the military and therefore might not be similar in the non-military environment.
Studies that do not support the staus quo help us improve and alter treatment directions. Although this study did not support early PT for LBP, it helps us move and discover new potential directions.
As authors note, study was under-powered, which could account for lack of differences between groups. The usual care in most LBP studies is 'advice to stay as active as possible'. The usual care in this study involved a very good education about LBP, and highlights the importance of this information in treating LBP. The need for a different outcome measures for patients with high-demand occupations is highlighted here. The Oswestry and Roland-Morris tools are not really suitable for military, athletes, etc. The long times of subjects off regular duties is a reflection of this. Overall, a well-designed study that should be replicated with much larger numbers, and perhaps a different measure than the ODI.
IT's very interesting that results showed no difference. This article speaks to the importance of moving away from work injury management towards population health management.