Acute low back pain with sciatica is common, sometimes debilitating, and usually disappears as mysteriously as it arrives. Outcomes research often focuses on the relatively few patients who don’t recover quickly. Early treatment options include primary care provider (PCP)-directed exercises, medications, and/or physical therapy, but there is a paucity of high-quality evidence for early referral for physical therapy. Researchers from the University of Utah aimed to remedy that with a randomized trial of early physical therapy referral compared to usual care.
They enrolled 220 patients with fewer than 90 days of back pain and symptoms consistent with nerve root compression extending below the knee. All were referred from primary care and had a score of at least 20 on the Oswestry Disability Index (ODI), a validated assessment tool in which higher scores between zero and 100 indicate more severe disability. Some participants had already received imaging or medications at enrollment. All were given a copy of The Back Book by Roland et al., advised to read it, and told to call their PCP for further management. Half were randomized to usual care determined by PCP and half were scheduled for an appointment with a physical therapist within three days. The two groups had similar characteristics, including baseline ODI scores. Physical therapy consisted of up to eight sessions over four weeks and included treatments such as high-velocity thrust manipulation of the spine, mobilization, traction, and exercise. Therapy-allocated patients were assigned exercises to be performed on days they were not seen, but in-session treatments were individualized.
At analysis, the patients in the physical therapy program had completed a mean of 5.5 sessions with few side effects. Follow-up was good, although an equally high number of participants in each group (about 42 percent) had off-protocol events such as visits with other providers, procedures, and either doing physical therapy in the usual care group or not attending appointments in the physical therapy group. Four weeks into the program, patients assigned to early physical therapy were more likely to report success than patients receiving usual care (relative risk [RR] 2.3, 95% CI 1.3-4.2), but this difference was not significant at six months and was smaller after one year (RR 1.6, 95% CI 1.1-2.4). A drop in ODI score of at least seven points is considered “clinically meaningful” by prior validation. Patients referred for early physical therapy had a drop of 8.2 (95% CI 4.3-12.1) more points at four weeks than the usual care group, and an additional drop was significant but not meaningful at six and 12 months. There was no difference between the groups in workdays lost.
This study shows some benefit at four weeks for early physical therapy referral, although the results were less impressive at later time points. Unfortunately, the extra attention paid to those in the physical therapy group, the heterogeneity in type and degree of interventions in both groups, and advice on home exercise only being given to the physical therapy group all confound the results of this study. Giving specific instructions to do graduated stretching and exercises is a routine part of sciatica care for most PCPs. At a minimum, instructions on home exercise would have been a more realistic baseline intervention for both groups. Another methodological limitation is the 42 percent of patients in both groups who had various off-protocol events. This study mimics real life, but the presence of this many confounders prevents firm conclusions. These data indicate that early physical therapy referral may offer some patients a faster improvement than usual care.
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