#VisualAbstract: Early physical therapy effective in reducing disability for patients with lower back pain

1. Early physical therapy (EPT) was more effective than usual care alone for reducing disability, back pain, and fear-avoidance beliefs at 4 weeks. Benefits in the former two extended with some attenuation to 1 year.

2. While health care use and missed work were similar between groups, patient-reported success was significantly higher in the EPT group at both the 4-week and 1-year time points.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Back pain is the costliest medical condition in the United States, with nearly 80% of the population experiencing symptoms at some point in their lives. Because many cases resolve spontaneously regardless of intervention, many providers elect to adopt a stepped-care approach in which referral to physical therapy is withheld until insufficient improvement from self-management is noted after some time. This study sought to determine whether physical therapy would be an effective first-line treatment for recent-onset (90 days or less) low back pain and sciatica, finding that patients who received early physical therapy (EPT) had significantly greater reductions in both Oswestry Disability Index scores and numeric back pain rating scale scores at 4 weeks compared to those who received usual care (UC). Further, between-group differences in favor of those who received EPT were detected in the two secondary outcomes of quality of life and self-reported health. Though the EPT group experienced sustained benefit over time, these observed differences diminished over 1 year due to substantial improvements that were eventually seen in the UC group. While these results support the more widespread utilization of physical therapy, they have somewhat limited generalizability because of considerable sample homogeneity and a failure to address risk stratification. Further research into specific patient populations may help identify subgroups that would reap the greatest benefit from EPT, thus allowing for greater precision in the targeting of therapy.

Click here to read the study in the Annals of Internal Medicine

Relevant Reading: Implications of early and guideline adherent physical therapy for low back pain on utilization and costs

In-Depth [randomized controlled trial]: This study was conducted in two healthcare systems in Salt Lake City, Utah. 220 patients were enrolled from February 2015 to October 2018 and randomized in a 1:1 ratio using permuted blocks to receive either EPT or UC, which consisted of only advice and education. The two groups were similar with regard to most demographic and clinical characteristics at baseline, but the UC group contained 10% more women than the EPT group, and over 80% of both groups were White. At 4 weeks, the EPT group had a −17.0 (95% CI, −19.7 to −14.2) point change in Oswestry Disability Index score compared to only a −8.8 (−11.5 to −6.0) point change in the UC group (relative difference, −8.2; 95% CI, −12.1 to −4.3). By 1 year, this difference had lessened to −4.8 (95% CI, −8.9 to −0.7) points, which no longer fell within the minimum clinically important difference range of 6 to 8 points. The same trend was observed in a 10-point back pain rating scale, for which the relative difference in mean change from baseline at 4 weeks was −1.4 (95% CI, −2.0 to −0.9) points at 4 weeks but diminished to −1.0 (−1.6 to −0.4) points at 1 year. Again, while between-group differences in improvement in EQ-5D quality of life (relative difference, 0.07 points on a 1-point scale; 95% CI, 0.02 to 0.11) and self-reported health (relative difference, 8.5 points on a 100-point scale; 95% CI 3.8 to 13.3) were statistically significant at 4 weeks, the two groups had similar scores at 1 year. Patient satisfaction appeared to be higher in the EPT group, however, as a greater percentage of participants self-reported success at both 4 weeks (28.6% versus 12.3%) and 1 year (45.2% versus 27.6%).

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