Low Back Pain & Timing of Referrals

Apollo imageThe 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. 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. This thinking led to a popular recommendation that physical therapy should be with-held for one to three months.

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. We now understand that the majority of LBP healthcare costs stem from reuse of the system. Therefore, the singular report of “recovery” that under-girded 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. 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.

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%
  • Need for injections reduced by 58%
  • Use of opioids reduced by 22%

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

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