A good therapist once told me that he would rather have a patient with low back pain see a bad therapist early, than a good one late. How many of us see patients who have had back pain for 15 years, without management. Nothing is better than getting the patient who responds extremely well to therapy, and we feel like we knocked it out of the park. If we are talking about low back pain, 50% improvement in 1 visit replicates that feeling. Therefore, we want as many prediction rules as we can in align to ensure success. Out of the list of options – duration of symptoms <16 days, low FABQW, symptoms above the knee, IR > 35 degrees, and a hypomobile segment – how long someone has had symptoms may be the easiest present a referral source can give us.3
Numerous studies have demonstrated duration of pain as a predictor of how well we do:
Physical therapy studies demonstrate its effect on prognosis…
Verkerk et al (2013):5 At 5-month follow-up, a shorter duration of complaints was a positive predictor of success.
Karstens et al (2013):4 “Predictors of success are impairment in daily life before therapy, mental disorders, duration of the complaints, self-prognosis on work ability, rheumatoid arthritis, age, form of stress at work and physical activity.”
Physicians have been speaking this same lingo…
Henschke et al (2008):6 “Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.”
The trend is pretty obvious here – Jones et al 2006 and Thomas et al both derived predictive factors and out spilled out with the pesky – duration of symptoms.7,8
If we have numerous pieces of literature telling us that people who develop chronic symptoms or do not respond well to therapy have had back pain for long durations – then why don’t we get this population in the office as soon as possible?
For a little more weight to the debate –
Patients not only prognostically do better when they see therapy earlier, but it saves the system money. Especially as we about a quarter of adults having LBP in the last 3 months which provides about 2% of all physician office visits.9 The cost alone of low back pain is almost 86 billion dollars per year.9 ,11 For perspective purposes, this is more than half of what we spend as a country on education per year (142 billion per year).10
A more personal note, as we are all looking to rid ourselves of student loans, if we cut that cost in half down to 43 billion per year, we could pay for 860,000 physical therapists to get their degree for free. I call dibs if we chose this model.
Gellhorn et al demonstrated that early PT (within 30 days) was strongly associated with decreased use of lumbosacral injections, physician office visits for low back pain, and lumbar surgery, when compared with PT that occurred at later times.1 Even stronger correlations were found in Fritz et al finding the above statement to be true but included less opiod medication use if patients were in a therapists office within 14 days. Total cost reduction was 2736$ per person lower with early initiation of physical therapy.11 Fortunately, the Midwest has shorter wait times to see a physical therapist when compared to the south, but is this fast enough? Still about 47% of patients are delayed into a physical therapists office.
Early care is a win-win situation. Patients get better faster, physical therapists have higher self-image as we are more successful, this model clears out primary care office visits of low back pain, and overall we see less health care costs. Therefore, my response to the patient who mentions that another family member battles with back pain and should seek care – I respond – I don’t care if he sees me or the other therapists in our area – just to hurry up and get in an office.
Original post: February 24, 2014
1) Gellhorn A, Chan L, Martin B, Fiedly J. Management Patterns in Acute Low Back Pain. Spine. 2010
2) Fritz J, Brennan G, Hunter S, Magel J. Initial Management Decisions After a New Consultation for Low Back Pain: Implications of the Usage of Physical Therapy for Subsequent Health Care Costs and Utilization. Archives of Physical Medicine and Rehab. 2013; 93: 808-813.
3) Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Gaber M, Allison S. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine 2002; 27: 2835-2843.
4) Karstens S, Hermann K, Frobose I, Weiler S. Predictors for Half-Year Outcome of Impairment in Daily Life for Back Pain: Patients Referred for Physiotherapy: A Prospective Observational Study. Physical Therapy. 2013; 8: 1587.
5) Verkerk K, Luijsterburg PA, Heymans MW, Ronchetti I, Pool-Goundzwaard AL. Prognosis and course of disability in patients with chronic nonspecific low back pain: a 5- and 12-month follow-up cohort study. Physical Therapy 2013; 93: 1603-14.
6) Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a17
7) Jones GT, Johnson RE, Wiles NJ, et al. Predicting persistent disabling low back pain in general practice: a prospective cohort study. Br J Gen Pract. 2006;56:334-341.
8) Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. BMJ. 1999;318:1662-1667.
9) Flynn T, Smith B, Chou R. Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm As Good. JOSPT. 2011; 41: 238-248.
10) US Education Spending. URL:http://www.usgovernmentspending.com/us_education_spending_20.html
11) Fritz J, Childs J, Wainner R, Flynn T. Primary Care Referral of Patients with Low Back Pain to Physical Therapy. Spine. 2012; 37: 2114-2121.