Promising data suggests rapid access to physical therapy may improve outcomes for patients with acute back pain, who typically wait much longer to receive evaluation from a physician.
By Thomas G. Ciccone
Interview with Michael Campian, DO, and Pamela Hansen, MD
Improving care for patients with low back pain could be as simple as providing immediate access to physical therapy.
A team of doctors at the University of Utah are experimenting with a new treatment protocol that provides patients with rapid access to a physical therapist when they call in to make an appointment. Instead of waiting the typical 4 to 6 weeks to be evaluated by a spine specialist, these patients can be treated by a physical therapist within 72 hours.
Physical therapy after an acute injury improves outcomes.
Since using the protocol, which has been running for over a year now, physicians are finding these patients may be having better clinical outcomes and needing fewer medical procedures, like radiographs and injections. According to Michael Campian, DO, and Pamela Hansen, MD, who both work at the University of Utah’s Orthopedic Center in Salt Lake City, Utah, the protocol is still in its early stages, but the evidence may show some promise.
“More often than not in these cases, a referral to a (physical therapist) is made. By first waiting for a physician visit, then waiting for (physical therapy) to start, it just delays treatment,” Drs. Campian and Hansen told Practical Pain Management in an email interview. “We are definitely starting to see a positive relation between patient outcomes with patients entering the rapid access protocol [RAP].”
“There is good evidence supporting maintaining normal activity level during acute back pain as an important factor in improving symptoms. Early access to [physical therapy] can give the patient education and reassurance, as well as appropriate exercises and encouragement to stay active,” they noted.
At this year’s annual meeting of the Association of Academic Physicians (AAP), Dr. Campian presented evidence compiled over the last year of the protocol’s existence.
Since January 1, 2016, a total of 68 patients have enrolled in RAP. For these patients, mean improvement in physical function has been significantly better compared to patients undergoing standard treatment protocols (5.6 vs 2.4, respectively; Patient-Reported Outcomes Measurement Information System [PROMIS]).1
Data also found that a lesser percentage of patients receiving RAP required medical interventions compared to other patients, including radiographs (24.1% vs 63.3%), MRIs (0% vs 16.9%), and injections (1.9% vs 0.8%).1
However, it may be difficult to determine whether this data proves that early access to a physical therapist can have a measurable impact on patient outcomes. It also may be too soon to tell if providing quick access to a physical therapist actually could save some patients from going through certain medical interventions.
“I think it is too difficult at this point to infer that symptoms will progressively worsen and incur more cost if they don’t seek early access to a physical therapist, because evidence does not support this,” noted the investigator. If there’s any cost savings to be had, it is more likely from patients being able to avoid a physician visit, particularly when they are suffering from uncomplicated, acute back pain, which can be effectively treated through physical therapy, Drs. Campian and Hansen told Practical Pain Management.
Whether other health care providers can adopt this protocol for low back pain treatment may be debatable, considering the success of Drs. Campian and Hansen’s program rests on the fact that both physical therapists and Physical Medicine and Rehabilitation (PM&R) spine specialists work under the same roof at the University of Utah’s Orthopedic Center.
“I believe it is an important factor in the success of the program. However, if this is not possible, it could still work as long as there is a good working relationship and line of communication between the two specialties,” they wrote.
Physical therapists can perform clinical screening of these patients on arrival, looking for any red flags that would warrant an immediate visit to the physician, like fevers, chills, unintentional weight loss, progressive neurologic symptoms, history of trauma, or severe pain that makes physical therapy intolerable. “On two occasions, patients have shown up in so much pain they were not able to participate in therapy and our therapists were able to have a physician evaluate them right away,” they wrote.
Another issue is whether patients’ insurance coverage is compatible for such a program. It should be noted that only patients insured for physical therapy visits sans a physician referral have been given access to the protocol. “Currently, we are only working with the insurance companies who do not require a referral to physical therapist. The reason for this is we don’t want the patient to receive an unexpected bill because of the lack of referral. Our goal is to change the system if we do find that this is the best approach to patient care. We want to make it a viable option for all patients.”
Drs. Campian and Hansen also intend to streamline their protocol further and continue collecting more data on the possible effects the rapid access protocol is having on their low back pain patients, looking into factors like time lost from work, patient satisfaction, health care cost savings, and utilization of resources. Some patients also appear to be opting out of the protocol, something the doctors would like to understand more about from the patient perspective.
This study was presented as part of the annual meeting of the Association of Academic Physicians.
Campian M, Hedin T, Hansen P, et al. Rapid access to physical therapy for low back pain: a continuous quality improvement project. Presented at: Annual Meeting of the Association of Academic Physiatrists; February, 2017; Sacramento, CA.