lbp update
TRANSCRIPT
Low Back Pain:A Current State of Affairs
Oh, the Aching Backs!
Eric K. Robertson, PT, DPT, OCS
Eric Robertson, PT, DPT, OCS, FAAOMPTUniversity of Texas at El Paso Continuing Education Series, Spring 2014
Our ObjectivesReview current epidemiology of LBP
Review current clinical guidelines for managing patients with LBP
Discuss psychologically informed practice as it relates to patients with LBP
Discuss optimal care pathways for patients with LBP
Relative Healthcare Costs
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Cost in Billions
Cardiovascular Disease
Relative Healthcare Costs
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Cost in Billions
Cardiovascular Dis-ease
CancerAll
Arthritis
Diabetes
LBP
Relative Healthcare Costs
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Cost in Billions
CHRONIC PAIN!
Cardiovascular Disease
Which of the following are predictors of LBP?
• Bulging disc without herniation or root contact
• Bulging disc without herniation but with nerve root contact
• Herniated/Prolapsed discs
• End plate changes / Shmorl’s nodes
• Foraminal or canal stenosis
Physical findings / Imaging
• History of depression
• History of occupational-related LBP
• Fearful beliefs about work as reported in a survey
Psychosocial findings
How did you do?
Physically:Only disc contact with nerve root has been
shown to be a WEAK predictor of LBP
Psychosocial:Depression, occupational injuries, and fear-
avoidance are all STRONG predictors of LBP
Implications in terms of pain?
Summary of LBP Predictors ?
Physical Psychosocial
Guideline Adherence for LBP
Adherent
Non-adherent
Worsening Trends in the
Management and Treatment of
Back PainMalfi et al. JAMA Int Med, 2013
“Despite numerous published national guidelines,
management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a
concomitant decrease in NSAID or acetaminophen use and no change in physical therapy
referrals. With health care costs soaring, improvements in the management of back pain
represent an area of potential cost savings for the health
care system while also improving the quality of
care.”
Things we know about LBP:
Incidence Second only to the common cold for reasons to see a doctor 25% of US population has had back pain within last 3 months
at any given time. Common Dx in PT Clinics everywhere!
Prognosis Favorable prognosis for simple, acute LBP!
Di Fabio & Boissonault (1998)
We have a problem…
Healthcare costs related to low back pain are climbing
Outcomes for low back pain are falling
According to Martin, Deyo et al., (2008 JAMA)
“…spine-related expenses have risen exponentially from 1997 – 2005 without evidence of improvement of self-assessed health status.”
Why?
Cause of LBP is unclear
Surgical Interventions
Imaging
Chronic LBP costs are high as a sub-group
Evolution of a Paradigm
Historically, the diagnosis of LBP has closely matched the tools with which we have had at our disposal to examine it. 1900’s – Nerve etiologies 1920’s – Muscle etiologies 1950’s – Bony etiologies (radiographs) 1980’s – Disc etiologies (MRI) –
However, this was discovered in 1938!
Back Pain Diagnoses in the 20th Century, Lutz et al., 2003
85%The percentage of low back pain of a non-specific nature.
So what about that imaging anyway?
MRI’s in Healthy Individuals
All Healthy Sign Anatom
HNP Facet Combined0
20
40
60
80
100
120
% of people
Findings on MRI
Do not predict who has LBP in either the chronic or acute state• Caragee et al, 2005, 2006; Borenstein et al, 2001; Savage et
al, 1997
Lead to higher rates of surgical intervention• Jarvik et al, 2003
Do not predict success or nonsuccess in rehabilitation or future disability• Caragee et al, 2005; Kleinsteuck et al, 2006
Inappropriate Imaging?
66% of CT and MRI ordered by primary MD’s in an HMO inapprop.
28-38% of California workers’ comp. MRI’s inappropriate
Higher use when MD owns imaging facility
All imaging tests increased 40% from 2000-2003; now $100 billion/year
Pharmaceuticals: 180% increase!
Martin, Deyo et al, JAMA, 2008
Deyo R, AAOMPT 2009
Deyo R, AAOMPT 2009
Spinal Instability?
"Spinal instability is routinely given as a diagnosis to these patients with chronic lower-back pain. It is a term used to justify an operation. And it‘s a great diagnosis, because it can't be directly disproved."
Deyo R, AAOMPT 2009
Spinal Fusion Surgery
Spinal-Fusion Surgery - The Case for RestraintDeyo RA et al. NEJM. 2004 350, Iss. 7; 722
Annual number of spinal-fusion operations rose by 77 percent between 1996 and 2001. In contrast, TKA and THA increased by 13 to 14 percent during the same interval
Financial Interests in Spine Surgery
Pedicle Screws at $13,000 per instrumented fusion surgery.• $4 billion per year!
Manufactures acknowledge giving surgeons millions in royalties, speaking fees, and research grants.• On-going government investigation of device makers
Government investigating illegal kickbacks.• Medtronic paid $40million in settlement
Ableson R, Peterson M; New York Times, 2003
Quote:
Dr. Seth Waldman:
"There will be a lot of people doing the wrong thing for back pain for a long time, until we finally figure it out. I just hope that we don't hurt too many people in the process."
Clinical Guidelines
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society. Chou et
al., 2007
Clinical Guideline: APS - APCChou et al., 2007 Annals of Internal Medicine
Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine
Clinical Guideline: APS - APCChou et al., 2007 Annals of Internal Medicine
Clinical Guideline: APS - APCChou et al., 2007 Annals of Internal Medicine
Clinical Guideline: APS - APCChou et al., 2007 Annals of Internal Medicine
Clinical Guideline: APS - APCChou et al., 2007 Annals of Internal Medicine
Acute LBP:
• Spinal Manipulation
Sub-Acute and Chronic LBP:
• Exercise• Yoga• Acupuncture• CBT• Spinal manipulation
635 Billion ReasonsOr, why addressing chronic pain is in everyone’s best interest.
PAIN#1 cause of adult disability in the US
PAIN1 in 6 People live with chronic pain.
PAINTotal annual direct costs for pain >$635B.
Relative Healthcare Costs
0
50
100
150
200
250
300
Cost in Billions
Cardiovascular Dis-ease
CancerAll
Arthritis
Diabetes
LBP
Relative Healthcare Costs
0
100
200
300
400
500
600
700
Cost in Billions
CHRONIC PAIN!
Cardiovascular Disease
Summary of LBP Predictors ?
Physical Psychosocial
Implications in terms of pain?
It might not be as much of a physical thing as we think!
We need to consider the cognitive components!
Nociception
Signal in 2nd order Neurons dominated by A-beta input
C/A-delt
a
A-beta
T-Cells
Nociceptive InputMechanical / Proprioceptive Input
GATE THEORY OF PAIN CONTROL SIMPLIFIED
Nociception
Noci means danger! Detecting danger.
All the way to thalmus is nociception. The thalmus is determining what should we tell the brain
Nociception can activate protective responses without us knowing about it…think withdrawal reflex from a hot stove
Nociception is NOT Pain Perception.
The perception of pain creates pain!
CRPS EXAMPLE Neurology, 2005- touching a mirror image of the non-painful hand creates pain and swelling in the painful side.
The perception of pain creates pain!
Also:Phantom limb painSeverity of Whiplash inversely related to
initial pain perceptionBattlefield injuries: little pain reported
So…you don’t need nociception to feel pain.
Pain the conscious version of nociception
Nociception Pain
Outside of awareness
Aware
InputOutput
Small pictureBig picture
Without emotionWith emotion
Relatively SimpleRelatively Complex
Pain is…
AN OUTPUTModern Pain Model: The Neuromatrix Paradigm Nociceptive signals are processed in the brain, mixed with
other sensory, emotional, cognitive, planning, and motor signals in the brain, and the resultant output is the pain perception.
How do we change pain perception?
What can we change Sensory input from body Social work environment Expected consequences Beliefs, knowledge
What can’t we change Previous experience Cultural Factors
Chronic Pain Models
We speak of pain processing primarily in terms of acute pain.
Pain that persists beyond nociceptive input is difficult to understand if you forget that pain is an output.
Chronic pain models can influence the way we treat patients.
Physical Psychosocial
Concept: The Body-self
Large loops of neurons between the thalamus and the cortex which allow parallel processing and permit:
An awareness of the body and unique and separate from the world
An orientation of the self as a point of awareness
Neuromatrix Paradigm
The collection of structures creating the body-self is called the neuromatrix.
The continuous output from this system is a neurosignature
The neurosignature is always present and allows us to perceive normal
We detect when it’s abnormal = pain
Melzack, Acta Anaesthesiol Scand 1999; 43: 880–884
Neuromatrix Paradigm
Explains how pain can be felt without nociception
Explains chronic pain
Explains how the brain changes in response to pain Up-regulation, increased receptor fields, more
efficient pain processing
Neuromatrix Paradigm
Body-Self
Pain?
PAIN MECHANISMS FOR WAD 57
From: Gifford, LS 1998
Identifying Patients at Risk for Chronic PainOriginally:
Waddell’s Non-organic Signs and Symptoms
Bottom Line:•None of the non-organic tests served as effective screening measures to predict development of chronic LBP
•Alternative screening tools are requiredFritz et al., 2000
Identifying Patients at Risk for Chronic Pain
Fear-avoidance model of musculoskeletal pain (FAM) (Measured by FABQ) Factors influencing pain perception
Anxiety Fear of re-injury Catastrophizing
AvoidanceConfrontation
AnxietyFear of re-injuryCatastrophizing
AnxietyFear of re-injuryCatastrophizing
George & Zepperi, JOSPT, July- 2009
Graded Exposure for Patients with Chronic Pain
George & Zepperi, JOSPT, July- 2009
Injury!
Infla
mm
atio
n
PA
IN
L
EV
EL
H E A L I N G R E S P O N S E
Pain from neurogenic origin
Pain from tissue damage
Adapted from Butler & Mosely, 2008, “Explain Pain”
FDAQ – A Measurement
George & Zepperi, JOSPT, July- 2009George et al., PTJ, July- 2009
General Principles
1. Chronic pain is not a local anatomical problem.
2. Pain perception influenced by common psychological conditions (FAB, depression).
General Principles
3. True psychogenic causes of pain are so rare as to not even be discussed much in rehab settings. Most patients we see have a reason to have pain (i.e. injury) and it is the processing of the pain that is altered.
4. Overt malingering is rare and cannot be detected by physical therapists (i.e. variation in maximum effort does not equal lack of effort).
General Principles
5. Graded approaches are a good way for PT's to incorporate cognitive-behavioral principles. The key is to focus on activity tolerance, NOT pain reduction.
6. If you are seeing a lot of chronic pain, consider a multidisciplinary approach, as that is where the evidence points to increased effectiveness.
Establishing a Baseline
Therapist: ‘How long can you walk before you flare-up?’
Patient: ‘I can walk for 30 min but I pay for it the next day’
Therapist: ‘Can you walk for 20 min without flaring up?’
Patient: ‘No, but I have’
Therapist: ‘Can you walk for 10 min without flaring up?’
Patient: ‘Probably not — definitely not up hills’
Therapist: ‘5 min on a flat surface?’
Patient: ‘Probably’
Therapist: ‘3 min on a flat surface?’
Patient: ‘Definitely’
Continuous Progression ‘every day you do more than you did
yesterday, but not much more’…at least initially.
Setting clear measurable goals and objectives!
KEY POINTS
Pain is not nociception
The representation of the body in the human brain
The brain changes as the pain persists
Body-brain is a 2 way street
Training the brain for people in Pain
Patient EducationPerhaps your most powerful analgesic tool is the ability to educate your patient about pain physiology.
Physical Therapists
We are the intersection of physiology & psychology!
A = Baseline Chronic Pain
C = Following Pain Education
B = Following HEP
One more thing…Is spinal manipulation appropriate for people with chronic pain?
Response to Thoracic Spine Manipulation: fMRI
Pre-Manipulation Post-Manipulation
Sparks et al, JOSPT 2013
Timing of Referral and Adherence to Best Practice for LBP:Does It Matter?
John D. Childs, PT, PhD, MBA
Non-invasive Interventions for Acute LBP
Intervention Net benefit Level of evidence
Spinal manipulation Small/Moderate Fair
Exercise therapy No benefit Good
Back schools Unclear Poor
Acupuncture Unclear Poor
Massage Unclear Poor
Interferential therapy, short-wave diathermy, ultrasound, lumbar supports, TENS
Unclear Poor
Non-invasive interventions for Chronic or Subacute LBP
Intervention Net benefit Level of evidence
Behavioral therapy Moderate Good
Exercise therapy Moderate Good
Interdisciplinary rehabilitation
Moderate Good
Spinal manipulation Moderate Good
Acupuncture Moderate Fair
Massage Moderate Fair
Yoga Moderate Fair (for Viniyoga)
Back schools Small Fair
Arch Intern Med. 2010;170(3):271-277
Methods
• Care provided in 3,533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines
• The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004)
Results
• Despite recommendations to the contrary• > 25% patients referred for imaging• Only 20.5% and 17.7% received care limited to advice
and simple analgesics, respectively• Analgesics provided were typically NSAIDs (37.4%) and opioids
(19.6%)
• This pattern of care was the same in the periods before and after the release of the local guideline
The timing of care matters.
Fuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12.
2011;41(11):838-846
Methods• National 20% sample of CMS outpatient claims
(Medicare)• Treatment for LBP between 2003-2004 (n=439,195).
• Patients with prior visit for back pain, lumbosacral injection, or lumbar surgery within the previous year were excluded
• Referral to physical therapy classified as• Acute – 0-4 weeks• -Subacute – 4 weeks – 3 months• Chronic – 3 months – 1 year
0.47 (95% CI, 0.44–0.50)
0.46 (95% CI, 0.44–0.49)
0.38 (95% CI, 0.36–0.41)
Gellhorn et al. 2012; 37: 775 – 782
There was a lower risk of subsequent medical service among patients who received PT early after an episode of acute LBP relative to those who received PT later.
Purpose
• Examine the cost implications of the decision to refer patients with a new episode of LBP from primary care providers to physical therapy and examine the influence of the timing of referral (early vs. delayed) and the content of the care (adherent vs. non adherent) received by physical therapists
SETTING Data extracted from Mercer HealthOnline® a database of members of employee-sponsored health plans.
Subjects
32,070 patients with a new primary care consultation for LBP from November 1, 2007 - January 31, 2009.
721.3 Lumbosacralspondylosis without myelopathy
722.1 Lumbar disk displacement
722.52 Lumbar / lumbosacral disc displacement
722.73 Lumbar disk deease with myelopathy
722.93 Other disk disorder lumbar region
724.02 Spinal stenosis - lumbar
724.3 Lumbago
724.3 Sciatica
724.4 Thoracic or lumbosacral neuritis or radiculitis
724.5 Backache, unspecified
756.11 Spondylolysis, lumbosacral region
756.11 Spondylolesthesis
846.0 Sprain lumbosacral
846.1 Sprain sacroilliac
846.8 Sprain – other sacroilliac region
847.2 Sprain lumbar region
,sprain - sacrum
847.3 sprain other specified sites of sacroiliac region
Subjects
Data Abstraction
• Patients meeting definition of new LBP episode visiting a primary care provider from November 1, 2007 through January 31, 2009
• Eligible patients had to be continuously eligible within the database for 6 months before and 18 months after the index date
• All healthcare visits, procedures, tests, prescription medications, etc. and associated billed charges
• CPT codes for each visit if patient received physical therapy
Inclusion/Exclusion
• Age 18-60 years old at index primary care visit• No prior spinal surgery • No evidence of non-musculoskeletal cause of LBP
diagnosis (e.g., infectious process, kidney stones, gall stones, urinary tract infection, cancer, osteomyelitis, etc.)
Timing:
1. Early Physical Therapy - 1-14 days from first Dr. visit (53%)
2. Delayed Physical Therapy - 15-90 days (47%)
Content:
3. Adherent - Active physical therapy based on CPT codes (22%)
2. Non adherent – Passive physical therapy (78%)
Groups
Covariates Examined
• Age and gender• Amount of co-payment for the index visit• Insurance plan (Point-of-service, Preferred Provider
Organization, Health Maintenance Organization , High deductible health plan, Other)
• Employment status (Active, Retiree, Long-term disability, Other)
• Geographic region (Northeast, South, Midwest, West)
Comorbidities• Co-morbid healthcare conditions in 6-month period prior to index date
• Number unique ICD-9 diagnoses recorded in any setting• Number of unique medications• If a hospitalization occurred • If narcotic medications were prescribed• Total allowed costs for all services (inpatient, outpatient and
prescription)
• Presence of co-morbid health conditions that may influence prognosis for individuals with LBP
• Mental health conditions (depression, anxiety, bipolar or other psychotic disorders)
• Concomitant neck or thoracic spine pain• Fibromyalgia
ACTIVE CODES PASSIVE CODES ALLOWED CODES
PHASE I
97110Therapeutic Exercise
97035 Ultrasound 97001PT Evaluation
97350Therapeutic Activity
97010Hot or Cold Pack
97002PT Re-Evaluation
97535Self Care Management Training
G0283,97032
Electrical Stimulation
99070Miscellaneous Supplies
97112Neuromuscular Re-Education
97012Mechanical Traction
97750
Physical Performance Test/Measure
97150Group Therapeutic Procedures
97124Massage Therapy
97140Manual Therapy
97113
Aquatic Therapy with Exercise
97116Gait Training Therapy
Phase 1: 1st 14 days of Episode of Care
ACTIVE CODES PASSIVE CODES ALLOWED CODES
PHASE II
97110Therapeutic Exercise
97140Manual Therapy
97001PT Evaluation
97350Therapeutic Activity
97035 Ultrasound 97002PT Re-Evaluation
97535Self Care Management Training
97010Hot or Cold Pack
99070Miscellaneous Supplies
97112Neuromuscular Re-Education
G0283,97032
Electrical Stimulation
97750
Physical Performance Test/Measure
97150Group Therapeutic Procedures
97012Mechanical Traction
97113
Aquatic Therapy with Exercise
97124Massage Therapy
97116Gait Training Therapy
Phase 2: >14 days
Determination of Adherence• Number of active and passive CPT codes at each visit within
each phase recorded• % of active to passive codes calculated as
• Number of active codes/(number of active codes + number of passive codes) x 100%
• Adherent care defined as % of active to passive codes at least 75%, with each visit including at least 1 active code
• Comparisons of costs between adherent vs. non-adherent care
All Patients(n=32,070)
Timing of Physical Therapy (n=2,077)
Content of Physical Therapy (n=1,917)
Early (n=1,102)
Delayed (n=975)
Adherent(n=413)
Non-Adherent (n=1504)
Advanced Imaging (MRI or CT)
18.9% 29.4% 54.9% 38.7% 43.9%
Physician Specialist Visits
44.1% 52.6% 81.0% 64.4% 68.8%
Lumbar Spine Surgery 2.5% 4.7% 9.9% 5.1% 8.1%
Lumbar Spinal Injections 7.1% 10.1% 21.2% 12.6% 17.8%
Narcotic Medication Use
49.1% 49.1% 55.3% 49.6% 53.2%
Table 2. Utilization of specific services for low back pain in the 18 month period following the index primary care visit
Table 3. Costs incurred over the 18 month period following the index primary care visit. Values represent mean (standard error).
All Patients(n=32,070)
Timing of Physical Therapy (n=2,077)
Content of Physical Therapy (n=1,917)
Early (n=1,102)
Delayed (n=975)
Adherent(n=413)
Non-Adherent (n=1504)
Imaging Procedures
$291.12(5.42)
$473.32(63.92)
$807.20 (42.12)
$513.84 (46.82)
$701.14 (52.32)
Physician Visits
$209.54 (1.48)
$259.62 (9.76)
$411.76 (11.89)
$295.52 (14.33)
$357.15 (9.86)
Surgical/ Injection Procedures
$740.44 (36.84)
$1018.88 (170.65)
$2760.62 (381.27)
$1445.23 (486.37)
$1965.72 (229.42)
Inpatient Non-Surgical Procedures
$79.28 (11.13)
$65.00 (30.58)
$231.79 (64.52)
$162.31 (90.20)
$142.99 (37.81)
All Patients
(n=32,070)
Timing of Physical Therapy (n=2,077)
Content of Physical Therapy (n=1,917)
Early (n=1,102)
Delayed (n=975)
Adherent(n=413)
Non-Adherent (n=1504)
Emergency Room Visits
$19.83(0.87)
$26.21(4.89)
$25.22(4.59)
$24.87(6.94)
$28.61(4.36)
Prescription Medication
$104.23(3.01)
$80.41(10.22)
$116.83(11.27)
$76.43(9.85)
$98.85(9.61)
Other LBP-related Costs
$437.89(8.11)
$1225.04(52.10)
$1531.3(67.01)
$1090.64(89.06)
$1651.73(53.07)
Total LBP costs
$1882.33(44.58)
$3148.49(228.90)
$5884.71(429.92)
$3608.83(533.49)
$4946.18(277.19)
Non-LBP healthcare costs
$7892.53(108.75)
$7169.22(472.39)
$8430.44(761.80)
$7254.82(1155.66)
$7511.44(402.09)
Table 3. Costs incurred over the 18 month period following the index primary care visit. Values represent mean (standard error).
53% 81%
49% 55%
10% 21%
4.7% 9.9%
29% 55%
Early PT Delayed PT
Utilization of Services
Figure 2. Likelihood of receiving specific services during the 18 month follow-up period based on non adherent physical therapy care.
$0.00
$500.00
$1,000.00
$1,500.00
$2,000.00
$2,500.00
$3,000.00
Other LBP
Related Costs
Prescription
Meds
Inpatient Non-Surgica
l
Procedures
Surgical/I
njection
ProceduresIm
aging
Procedures
Total Costs: $3148 $5884
Early PTDelayed PT
Early Physical Therapy Delayed Physical Therapy$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
Other LBP-related Costs
Prescription Medication
Emergency Room Visits
Inpatient Non-Surgical Procedures
Surgical/ Injection Procedures
Physician Visits
Imaging Procedures
Total Costs: $3148 $5884
Implications of Timing and Quality of Physical Therapy on Low Back Pain Utilization and Costs
in the Military Health System
John D. Childs, PT, PhD, MBA
Samuel S. Wu, PhD
Eric Robertson, PT, DPT
Forest S. Kim PhD, MHA, MBA
Robert S. Wainner, PT, PhD
Timothy W. Flynn, PT, PhD
Steven Z. George, PT, PhD
Julie M. Fritz, PT, PhD
Background• Back pain & arthritis the most costly conditions requiring rehabilitation
in the U.S.• Over $200 billion per year, exceeding total costs associated with spinal cord
injury, traumatic brain injury, stroke, multiple sclerosis, and limb loss
• Studies demonstrate that the vast majority of costs are incurred early in the care process
• Many studies demonstrate lack of adherence to practice guidelines for managing LBP
• Previous work has demonstrated that timing of referral and adherence to practice guidelines reduces utilization and costs
• Military Health System offers compelling opportunity to expand this work because a single payer system
Methods
• Extract LBP ICD-9 codes from Jan 1, 2007 through Dec 31, 2009
• Extract full history of these cases from Jan 1, 2006-Dec 31, 2011• Determine previous medical history for 1-year preceding the index visit• Conduct 2-year follow-up from index visit
• Newly consulting LBP defined as no claims with a LBP-related ICD-9 code for 6 months preceding the index date
Inclusion/Exclusion• Age between 18-60 years of age at index date
• Continuously eligible within database 12 months before (to capture co-morbidities and previous history) and 24 months after index date
• No co-morbid diagnosis within 4 weeks of index date that could be nonmusculoskeletal source of LBP (e.g, kidney stones, urinary tract infection, etc .)
• No prior history of spinal surgery or trauma (ie. fx) based on the presence of related current procedural terminology (CPT) codes at any time prior to the index date
• Only the first eligible index date for an individual patient included to avoid overlap in episodes of care. (ie – individual patients can only appear once in dataset)
Analysis• Considered 90-day period after the primary care index date to identify PT
utilization• If a PT visit occurred with a LBP-related ICD-9 during this period, patient
defined as utilizing PT• Early PT defined as utilizing PT within 14 days from primary care index date• All PT episodes without a primary care index date (ie, direct access) classified
as early• Late PT defined as utilizing PT between 15-90 days from index date
• Patients with both PT and chiropractic utilization for LBP excluded
• Adherence determined using the same algorithm previously published (Fritz, Spine, 2012)
• Controlled for co-morbidities similar to previous research (Fritz, Spine, 2012)
883,969 continuously eligible patients with primary care for low
back pain.
Age <18 & >60 years(n=13,992)
Low back pain claim in the past 6 months (n=38,955)
Possible non-musculoskeletal low back
pain (n=154,729)
Prior surgery for low back pain (n=148)
676,145 patients included in analysis
Inclusion and Exclusion Criteria
Groups and Demographics
All Patients
(n=676,145)
PT Users(n=158,2
71)
Timing of PT Adherence
Early(n=59,4
16)
Delayed(n=98,8
55)
Adherent
(n=23,550)
Non‐Adherent
(n=32,750)Age (mean, sd) 33.8
(11.2)33.3
(10.5)32.2
(10.4)34.0
(10.6)34.8
(11.3)36.1
(11.2)Gender (% female) 39.10% 34.10% 32.80% 34.90% 41.80% 45.30%Common Beneficiary Category
Spouse/families 19.80% 14.50% 13.10% 15.30% 20.60% 22.80%Retired 10.10% 7.30% 5.80% 8.10% 11.20% 11.70%Other 12.80% 8.80% 8.00% 9.30% 13.20% 14.90%Active Duty 57.30% 69.50% 73.10% 67.20% 55.00% 50.70%
Additional Covariates
All Patients(n=676,145
)PT Users
(n=158,271)
Timing of PT Adherence
Early(n=59,416)
Delayed(n=98,855)
Adherent(n=23,550)
Non‐Adherent
(n=32,750)Number of LBP diagnosis codes
(mean, sd)1.5
(1.8)1.4 1.5)
1.4(1.2)
1.4(1.6)
1.5(1.7)
1.7(1.9)
Number of prescription medications
(mean, sd)13.6
(10.3)15.2
(10.8)12.9(9.9)
16.5(11.0)
15.9(11.1)
16.4(11.3)
Co morbid mental health condition‐ 0.082 0.084 0.078 0.088 0.09 0.088Co morbid fibromyalgia diagnosis‐ 0.019 0.017 0.016 0.018 0.02 0.023
Co morbid neck/thoracic spine ‐condition 0.108 0.118 0.129 0.111 0.116 0.142
Narcotic use prior to index visit 34.10% 35.20% 34.10% 35.90% 37.50% 38.40%Hospitalization prior to index visit 7.20% 7.10% 6.90% 7.20% 8.40% 8.50%Total medical costs prior to index
visit(mean, sd)
$3608.26(8017.10)
$3704.36(7795.80)
$3617.90(8189.26)
$3756.35(7548.91)
$4119.76(10271.64)
$4069.42(7558.78)
Adjusted Odds Ratios & 99% CIs
E vs. D A vs. NAAdvanced Imaging .47 (.45, .49) .68 (.64, .72)
Lumbar surgery .52 (.47, .56) .80 (.71, .91)
Spinal injection .47 (.45, .49) .78 (.73, .83)
Opioid use .48 (.47, .50) .93 (.89, .98)
12%
3%
8%
59%
Early Delayed
Utilization of Services – Timing of Care
Advanced imaging(MRI or CT)
Lumbar spine surgery
Lumbar spinal injections
Opioid medication use
23%
4%
17%
75%
23%
2%
14%
71%
Adherent Non-adherent
Utilization of Services – Guideline Adherence
Advanced imaging(MRI or CT)
Lumbar spine surgery
Lumbar spinal injections
Opioid medication use
30%
4%
18%
73%
13% 20%
2% 3%
9% 13%
61% 64%
E/AAdvanced imaging(MRI or CT)
Lumbar spine surgery
Lumbar spinal injections
Opioid medication use
D/NAE/NA D/A
27%
4%
17%
77%
35%
5%
21%
78%
Utilization of Services – Timing & Guideline Adherence
Prescription meds$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$733$859
$983$1,145
Total Costs Incurred Over 2-year Follow-up
E/A E/NA L/A L/NA
Inpatient$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$11,407 $10,521$13,030 $13,506
Total Costs Incurred Over 2-year Follow-up
E/A E/NA L/A L/NA
Total LBP$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
$2,110$2,784
$3,670$4,340
Total Costs Incurred Over 2-year Follow-up
E/A E/NA L/A L/NA
Non LBP-related$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$8,470 $8,459$10,380 $10,589
Total Costs Incurred Over 2-year Follow-up
E/A E/NA L/A L/NA
Low quality physical therapy delivered early is better than
current standard of care for back pain management in the U.S.
High quality physical therapy delivered
early is even better
Acknowledgements
• This study is funded in part by the following organizations:
• U.S. Air Force Medical Service Intramural Grant Program
• Texas State University Faculty Grant
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