LBP Update

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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Cardiovascular Disease


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Cardiovascular Dis-ease

CancerAll

Arthritis

Diabetes

LBP


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CHRONIC PAIN!


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

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


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.


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Cost in Billions

Cardiovascular Dis-ease

CancerAll

Arthritis

Diabetes

LBP


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700

Cost in Billions

CHRONIC PAIN!


Summary of LBP Predictors ?


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.


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


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


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)



Early (n=1,102)

Delayed (n=975)

Adherent(n=413)


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)



Early (n=1,102)

Delayed (n=975)

Adherent(n=413)


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)




30%

4%

18%

73%

13% 20%

2% 3%

9% 13%

61% 64%

E/AAdvanced imaging(MRI or CT)




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


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


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


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

References1. mischvalente. back pain.; 2008. Available at: http://www.flickr.com/photos/mamibodega/2931602556/ [Accessed July 12, 2009].2. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656-664. 3. Groupman J. Annals of Medicine: A Knife in the Back: The New Yorker. 2002. Available at: http://www.newyorker.com/archive/2002/04/08/020408fa_FACT [Accessed July 13, 2009].4. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery - the case for restraint. N. Engl. J. Med. 2004;350(7):722-726. 5. Deyo R, Mirza S. The case for restraint in spinal surgery: does quality management have a role to play? Eur Spine J. 2009. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19266220 [Accessed July 14, 2009]. 6. Dave. stop back pain.; 2007. Available at: http://www.flickr.com/photos/funkypancake/1478208586/ [Accessed July 12, 2009].7. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8-20. 8. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34(10):1094-1109. 9. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical practice guideline. Spine. 2009;34(10):1078-1093. 10. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472.

http://www.flickr.com/photos/mamibodega/2931602556/

http://www.newyorker.com/archive/2002/04/08/020408fa_FACT

http://www.ncbi.nlm.nih.gov/pubmed/19266220

http://www.flickr.com/photos/funkypancake/1478208586/

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