Referral to Physical Therapy for Low Back Pain reduces odds of later opioid prescription
There is solid evidence that physical therapy as a first line approach for low back pain improves outcomes, but few studies are focused on the factors associated with referral to physical therapy in the first place, regardless of later participation in treatment. Now researchers believe they found associations indicating that the very act of referral for physical therapy may point to the ways a primary care providers approach to low back pain can affect patients’ perceptions and reduce odds of late opioid use-even when the patient doesn’t follow through with the referral.
The study published in the Journal of the American Board of family medicine, looked at data from 450 for Medicaid enrollees who initially were treated by a primary care provider for low back pain. Of those, 215 received a referral for physical therapy. While researchers were interested in differences between the referral and non-referral groups, the target of the study was something they believed is missing in current research center: an examination of the entire for a population, regardless of whether those patients followed up with actual physical therapy.
“Identifying only patients who have participated in physical therapy fails to account for the impact of the referral itself” the authors wrote. “The referral potentially represents a provider-patient interaction about the nature of the low back pain and prognosis. Improved outcomes among physical therapy cohorts may represent a combination of patient compliance with the physical therapy recommendation and a provider’s beliefs about the nature and severity of the low back pain.”
To explore this issue, researchers divided patients who received the physical therapy referral into two groups-- those who, after physical therapy consultation, went on to participate in physical therapy, and those who didn’t. Researchers compared those groups with each other, as well as with the group that didn’t receive any referral to physical therapy.
Among the findings:
Patients receiving a physical therapy consult tended to be younger, and had received a radiograph and/or a prescription for non-steroidal anti-inflammatory drugs (NSAIDS) or muscle relaxer‘s. Patient less likely to receive a consult were associated with tobacco use, chronic pain, depression, 2 or more comorbidities, and having received a referral for specialty care or advanced imaging.
The odds of a patient receiving a physical therapy consult increased 1.8 times if the patient also received an NSAID prescription.
In terms of actual participation in physical therapy, patients who receive multiple orders from the primary care provider (specialty referrals, advance imaging, etc.) in addition to a physical therapy referral were less likely to go to physical therapy, as were older patients and those of two or more comorbidities.
Opioid prescriptions were the most commonly used interventions during the year after the initial low back pain visit. While the strongest predictor of a later opioid prescription was associated with whether and opioid prescription occurred at baseline, patients who received a physical therapy consult were 35% less likely to receive an opioid prescription, regardless of whether they participated in physical therapy after the consult.
The authors wrote, “These results highlight the impact of the initial provider visit and provide foundation for future work understanding patient and provider beliefs surrounding the initial primary visit for low back pain,” adding that “providing a physical therapy consult in place of an opioid prescription is a reasonable alternate strategy for pain management and improved function, particularly in this population of Medicaid enrollees.”
The researchers added, “Patients with a consult to physical therapy represent a unique and important subset, as the consult me represent a reflection of the providers values and subsequent communication with the patient. Recommending physical therapy provides reassurance to patients that their low back pain is best managed with physical activity and is in line with advice to stay active. This in itself has potential to change cost and health care use.
Authors of the study include APTA members Anne Thackeray, PT, PHD, and Julie Fritz, PT, PhD, FAPTA
If you are suffering from chronic back pain and have tried massage, rest, or medications that have just not caused a substantial change in your low back pain, then consider physical therapy.
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