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Wait-and-See Does Not Create Important Savings in Low Back Pain Treatment

In 2017, low-back pain (LBP) caused 65 million years lived with disability. That was 17.5% worse than in 2007.

What’s more, two thirds of people with low back pain continue to experience pain at 12 months.2 To help save insurance dollars in the treatment of LBP, some strategize that physiotherapy should be withheld until after a period of waiting. In as much as most patients already practiced wait-and see before seeing the doctor, it’s unclear how another round of wait-and-see benefits patients.

For instance, later physiotherapy referrals have worse outcomes for patients compared to early referrals.3 Moreover, there is not consistent evidence supporting the hypothesis that wait-and-see reduces insurance spending. While several studies show improved outcomes and cost savings associated with immediate referrals to physiotherapy compared to later referrals, studies comparing early referrals to usualcare reach differing conclusions.3 For more help with this question, Majd Marrache and colleagues conducted the largest analysis to date.3 They analysed the insurance records of 980,000 adults with orthopaedic low back pain. They excluded anyone who had sought care for LBP in the previous three months. They found that people who received physiotherapy within two weeks of the doctor’s visit cost the insurance companies $70 US less in the first 30 days but $78 US more over the course of the following year. While the differences are statistically significant, they are not meaningful. People not in the early physiotherapy group may or may not have received any physiotherapy. Therefore, researchers structured this study to address the question, “What if every patient had first-line access to physiotherapy?”

This very high-powered study with nearly a million subjects concludes that early physiotherapy pays for itself by reducing other healthcare spending. Early physiotherapy cut the likelihood of emergency department visits by half, pain specialist visits in half, advanced imaging by 43%, orthopaedists by 23%, chiropractic by 59%, and epidural steroid injections by 32%. Withholding physiotherapy in non-specific low back pain does not save money. It shifts spending to emergency departments, advanced imaging, injections, and other healthcare spending.

Despite being high powered, the current study had noteworthy limitations. The database only includes patients age 18 to 65. Researchers defined early physiotherapy as at least one physiotherapy visit in two weeks. In this case, an unknown percentage of subjects in that group may have received the majority of their visits after two weeks. Some recent studies have defined early physiotherapy as an immediate referral with physiotherapy occurring within 72 hours. Additionally, two-thirds of the study subjects had received healthcare for LBP within the past six months, opening the possibility that many in the early group were actually late. Other recent studies limited their groups to patients who had not reported back pain in the past six or 12 months. While the current study finds results supportive of early physiotherapy referrals, these results may be understated compared to the stricter definitions of “early” or “immediate” in other recent studies. The current study was not structured to assess differences in clinical outcomes. However, previous studies give us some evidence. Frogner et al. find that physiotherapy on day one reduces the need for opioids 89%.5 Fritz et al. find that immediate physiotherapy improves quality of life in a way that is considered cost-effective by international standards.6


1. Gianola S, Bargeri S, Del Castillo G, Corbetta D, Turolla A, Andreano A, Moja L, Castellini G. Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis. British Journal of Sports Medicine. 2022 Jan 1;56 (1):41-50.

2. Costa LD, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012 Aug 7;184(11):E613-24.

3. 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.

4. Marrache M, Prasad N, Margalit A, Nayar SK, Best MJ, Fritz JM, Skolasky RL. Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database. BMC Health Services Research. 2022 Dec;22(1):1-9.

5. Frogner BK, Harwood K, Andrilla CH, Schwartz M, Pines JM. Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Services Research. 2018 May 23. DOI: 10.1111/1475-6773.12984

6. Fritz JM, Kim M, Magel JS, Asche CV. Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial. Spine. 2017 Mar 1;42(5):285-90.

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