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The Effect of Physiotherapy Timing on Low Back Pain Spending & Outcomes

Across Australia, the cost of low back pain is on the rise, but outcomes are not improving.1 The healthcare community continues to search for methods that will improve outcomes for patients.

Not only will this benefit patients, it will benefit payors. The vast majority of costs associated with low back pain do not come from the initial episode. They come from recurrence. Therefore, improving outcomes early can improve expenses long-term.
Earlier utilisation of physiotherapy stands out as a promising proposal for improving outcomes. In December 2018, we summarized various studies showing how immediate referral to physiotherapy can improve outcomes while reducing subsequent healthcare utilisation. Recently, Elizabeth Arnold and colleagues from a major university’s medical school in the U.S. conducted a first-of-its-kind meta-analysis including these studies and more.2 While there have been other systematic reviews and metaanalyses demonstrating the improved outcomes available through earlier referral, the current study is the first to focus on non-specific low back pain (LBP) exclusively and the first to combine data comparing early physio to usual care without physio. They combined the results of 11 studies.
When comparing early physiotherapy to later physiotherapy, the evidence is clear. Earlier physio reduces one and two year healthcare utilisation including opioid use, injections, imaging, and surgery. This results in direct costs lowered by $1,011 to $2,736 over one to two years. 
Arnold et al. found that there was not enough data to make a conclusive statement about the effect of early physio compared to usual care without physiotherapy. Across different studies, early physio was associated with increased healthcare, decreased healthcare, or no effect.  The authors were diligent to note that not all trials included in this portion of the analysis were randomised or controlled, and this may have affected the results.

Patients with more severe pain and disability prove more likely to use physiotherapy. Therefore, reviews of insurance records and similar methods could be comparing groups with important differences. Additionally, one of their studies involved military personnel. This group is known to be younger, predominantly male, and routinely enrolled in physical training. Their results may not be generalizable to a normal patient population. 
Furthermore, the authors point out that not all their comparisons between early physio and usual care controlled for the type of rehabilitation delivered. Reviews of insurance records have found that (1) active care produces superior outcomes over strictly passive care and (2) many if not the majority of files studied used strictly passive care during the first weeks of LBP treatment.3-5 
In short, there are not enough studies effectively comparing the difference between evidence -based early physio and usual care. However, we can still reach some important conclusions. Later physiotherapy for LBP has worse outcomes than earlier referral. Therefore, a waitand-see approach will produce worse outcomes.

The goal is to establish with as much accuracy as possible which patients will need physiotherapy at some point and to give them access to active treatment as soon as possible. Studies comparing usual care with and without early physiotherapy will probably need to differentiate groups of patients, use evidencebased physiotherapy, and use generalizable patient groups to be useful clinically. 

1. Australian Institute of Health and Welfare 2016. Impacts of chronic back problems. Bulletin 137. Cat. no. AUS 204. Canberra: AIHW. 
2. Arnold E, La Barrie J, DaSilva L, Patti M, Goode A, Clewley D. The impact of timing of physical therapy for acute low back pain on health services utilization: a systematic review. Archives of Physical Medicine and Rehabilitation. 2019. 
3. Childs JD, Fritz JM, Wu SS, Flynn TW, Wainner RS, Robertson EK, Kim FS, George SZ. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research. 2015 Jun;15(1):150. 
4. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012 Dec 1;37 (25):2114-21. 
5. Nordeman L, Nilsson B, Möller M, Gunnarsson R. Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial. The Clinical Journal of Pain. 2006 Jul 1;22(6):505-11. 

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