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Back Pain: Immediate Physiotherapy Cost-Effective at Improving Quality of Life

For decades, the dominant philosophy governing treatment recommendations for uncomplicated low back pain (LBP) was that LBP was a self-limiting “injury” that healed on its own in the majority of cases.

This thinking led to a popular recommendation that physiotherapy should be withheld for one to three months.2-4 While this rationale has been thoroughly discredited, language about LBP’s benign and self-limiting nature still reverberates in medical literature today.5 Across Australia, the estimated cost of back pain problems to the community is $4.8 billion and on the rise. Seventy-five percent of those expenses stem from indirect costs such as time off work, and the majority of those costs accrue from recurrence and chronicity rather than singular complaints.6 The current scientific knowledge shows that nonspecific LBP behaves less like an injury that can simply heal and more like a deconditioning syndrome that is self-worsening without intervention. Acute flare-ups of pain without any real source of trauma announce the progression of a deconditioning syndrome and present an optimal window to begin active, supervised care.7 Nevertheless, the majority of patients begin active, supervised physiotherapy weeks after their initial presentation to the healthcare system for LBP, if they receive physiotherapy at all.
One question stemming from the new understanding of nonspecific low back pain is whether the benefits of immediate access to physiotherapy justify the cost. Julie Fritz and colleagues addressed this question in their research recently published in Spine.8 They randomised 220 patients with LBP < 16 days into two groups: a group with delayed access to physiotherapy to allow time for spontaneous recovery versus a group given immediate referral to physiotherapy during the acute phase. After one year, the group with immediate access to physiotherapy cost $580 USD more but had significantly greater quality of life as measured by the EuroQoL EQ-5D. 
How much is quality of life worth? The incremental cost-effectiveness ratio (ICER) for immediate access to physiotherapy during the acute phase was $32,058 USD. In Australia, a new drug with a cost less than $50,000 AD per
ICER gained is more likely to be recommended for funding by the Pharmaceutical Benefits Advisory Committee.9 The United Kingdom’s National Institute for Health and Care Excellence sets the official ICER threshold at $40,000 USD.10 By these standards, the higher quality of life achieved in the current study would be considered worth the additional $580 USD spent for immediate access to physiotherapy during the acute phase.
While previous studies agree that earlier access to physiotherapy improves outcomes, earlier research has suggested greater cost savings available through physiotherapy. A 2017 study shows immediate access to physiotherapy reduces other healthcare spending: radiographs (24.1% vs 63.3%), MRIs (0 vs 16.9%), and injections (1.9% vs 20.8%).11 A study that Spine published in 2012 shows that patients who begin physiotherapy within 14 days of their primary care consult cost $3,058 less than those who begin physiotherapy later and are 55% less likely to need surgery.8 Similarly, an ambitious metaanalysis published in the Journal of Occupational Rehabilitation finds that delayed treatment predicts longer time off work.12 Research suggests that more rapid access to physiotherapy would do more to curb Australia’s challenges with LBP disability than attempts to cut short-term costs by withholding or lessening treatment based on duration of an individual episode of pain.  

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