Lower back pain (LBP) is the leading cause of disability worldwide and amounts to billions of dollars in healthcare costs. For many LBP patients, the emergency room (ER) is their gateway to the wider healthcare system. However, nearly 95% of LBP cases examined in the ER are determined as not urgent. These cases typically resolve within a few weeks, but not without these patients suffering pain and disability. When seeking medical care, people with LBP often receive treatment that does not align with best practices and can rely heavily on pain-relieving drugs. This type of approach does not work for all LBP patients, and can be the opposite of what most clinical guidelines recommend.
Year after year, these clinical guidelines advocate for increasing initial treatments for LBP that don’t include drugs and surgery. With more information, many physicians are now beginning to prescribe one kind of treatment after an ER visit that can deliver significant pain relief, can have almost no side effects, and be even cheaper in the long term. That treatment is physiotherapy (PT), perhaps better known as physical therapy.
But even with the known benefits of PT, clinical guidelines still suggest a delay in sending patients to PT to allow for spontaneous LBP recovery. However, new research is showing that earlier access to PT can result in better patient outcomes and save money.
Research published in the Physical Therapy & Rehabilitation Journal by Jake Magel, PT, PhD, DSc, the University of Utah, US, investigated how moving patients more quickly from the ER to PT could affect LBP patient outcomes. The research suggested that earlier access to PT lowers the risk of surgery and long-term opioid use, and substantially lowers healthcare costs.
The study involved 2,473 LBP patients from the Utah region. From this cohort, 269 patients began using PT for their LBP within three months of their initial ER visit. The researchers learned that these patients who started using PT within three months following a new ER visit were older, had more conditions aside from LBP, and were more likely to have already undergone surgery. These PT users were also more likely to have medical insurance and use prescription pain medication.
When talking about the study, Magel, the lead author, commented that their research “… shows that if an LBP patient desires or needs PT following an ER visit that the earlier they attend it, the better, as it is superior to delaying PT. Healthcare providers and patients can expect to use fewer healthcare resources and typically pay less when accessing early PT.”
Of the 269 PT users in this study, 65% initiated PT early (i.e., within 30 days), and 35% delayed PT (i.e., within 31-90 days). Magel states that one year after an ER visit for LBP, accessing earlier PT “protected patients against surgery and long-term opioid use after the initial ER visit, in comparison to patients who delayed PT.” Importantly, the study also showed that initiating PT early was an extremely cost-effective option for the healthcare system, resulting in almost $5,000 saved per patient every year.
The Role of PT in curbing the North American opioid epidemic
The study found that LBP patients accessing PT earlier had a 23% less chance of long-term opioid use. In the United States, opioids accounted for roughly 19% of medication prescriptions for LBP, of which 77% are prescribed for long-term use. Amid the current opioid crisis, shifting PT to the forefront of the patient experience could offer a safe and effective alternative to opioids.
Steven George, PT, PhD, the director of musculoskeletal research at Duke University, North Carolina, US, believes that physical therapists play the role of demonstrating to individuals with LBP that there are non-drug alternatives that can be tried, instead of going straight to opioid use. “There are certainly indications for opioids to be part of a pain management program, but too often in North America they are provided in a manner that is not indicated by current clinical guidelines. PT offers an alternative option for pain relief that for many patients may provide a way to remain functional and not use opioids,” said George.
Using opioid medications alone to control pain only partially address the problem of LBP. Joshua Lee, PT, PhD, a physical therapist and fellow at the University of Western Ontario, Canada, commented, “We now understand pain to be a combination experience that is created by complex biological, psychological, and social interactions. I believe that physical therapists, at their core, help people rediscover a sense of purpose and build functional strength to achieve those purposes.”
Magel believes that physical therapists play a major role in addressing the opioid epidemic “by advocating for earlier access to PT in order to prevent opioid initiation and also identify patients who may potentially be at risk for prescription opioid misuse.”
Researchers in this study suggested that long wait times for primary care appointments may force LBP patients to seek initial care in the ER. The goal is not to completely eliminate opioid use, but rather show that earlier access to PT, or even deploying physical therapists within the ER for direct access, can be beneficial for providing timely and cost-effective care, and potentially reduce long-term opioid use and misuse.
“There’s good evidence that physical therapists in the ER can help to prevent increased healthcare utilization and help to educate the patient. Although physical therapists in the ER are not new, it is uncommon. Having a physical therapist in the ER will help patients get early access to PT and possibly prevent this lag from ER discharge to attending PT,” said Magel.
Deploying physical therapists in the ER can help to triage patients, and working together with ER physicians can help to provide a link to fast-track the rehabilitation process. “This process can lead to a quicker recovery, potentially saving thousands of dollars in medical procedures,” said Lee.
Implementing ER physical therapists may not only reduce the burden on ER physicians through triaging and consultation, but they can also provide alternative forms of pain management, such as therapeutic exercises to encourage early movement, and detailed instructions for self-management that are aligned with current clinical guidelines.
Educating patients on the timeliness of PT
The study indicated that only 11% of these LBP patients had spoken with a physical therapist after an ER visit. This finding reinforces the importance of patient education to increase patient awareness of the clinical and cost benefits of attending earlier PT for LBP. However, without the prescription, encouragement, and most importantly individualized education from ER care providers, patients can be left stranded and forced to navigate appropriate pain management alone after they’re discharged.
George agrees that ER physicians need to educate patients on the importance of attending early PT, but also adds the need to make sure there are clear and established pathways to refer LBP patients to PT more quickly. “We can have the [ER] physicians educated all we want, but if there are not clear actions for them to [refer patients], then the rates will not change,” he commented.
Healthcare providers should prioritize educating LBP patients on staying active and attending early, supervised PT once they are discharged from the ER, rather than quickly resorting to pain-relieving drugs or prolonged bed rest. Not only could this lead to better patient outcomes, but also save money for both the patients and healthcare system in the long term.
According to Stephanie Eucker, MD, PhD, an ER physician from Duke University, this study’s findings will help support these types of discussions between patients and ER care providers. “Early PT referrals are both clinically effective in reducing opioid use and future surgery, as well as being effective at reducing overall healthcare costs,” Eucker said.
Improving access to PT is essential to patient-centered care
One important consideration of this study is that only patients from a single statewide database, with continuous access to insurance that covers PT, were included. These results may differ when looking at LBP in other geographic areas or more limited access to PT.
The study showed that early PT users were more likely to be insured by commercial plans or Medicare in comparison to the delayed PT group. Given the costs associated with attending PT, gaining direct and earlier access to PT services may create a financial barrier for many LBP patients. Studies have shown that financial barriers are a leading cause for the low referrals and attendance rates to PT. “From our other research, the number one reason why patients don’t access PT is cost,” said Magel. Due to its cost-effectiveness and the well-documented benefits of LBP patients attending early PT, it is important to create equitable policies that improve clinical care pathways and decrease the financial barriers to PT.
“For certain conditions, we should absolutely improve the access to PT and minimize out-of-pocket expenses. I think through working with individual insurance companies, one solution could be to explore innovative care models where LBP patients can access early PT and have their co-pay insurance waived for a certain number of early visits, making it easier to access the care needed,” said Magel.
In Ontario, Canada, recent policy changes have allocated funds toward expanding the role of physical therapists in primary healthcare and integrating physical therapists into interprofessional teams. For LBP patients, Ontario has developed publicly funded Inter-professional Spine Assessment and Education Clinics that provide rapid access to physical therapists. This has resulted in reduced wait times and improved access to PT, as well as limiting unnecessary healthcare costs.
PT is essential for helping LBP patients return to the activities of daily living and for sustaining a cost-effective healthcare system. LBP management goes beyond the ER. Ensuring timely and equitable access to PT embodies patient-centered care. PT, after all, shouldn’t be seen as a privilege – it is a fundamental extension and portion of healthcare for everyone.
Prab Ajrawat, MSc, is a researcher at the University of Toronto, Canada, and a patient advisor with the Solutions for Kids in Pain (SKIP) Patient and Caregiver Advisory Committee.