Author Names
Farrokhi, S. Bechard, L. Gorczynski, S. Patterson, C. Kakyomya, J. Hendershot, B. Condon, R. Perkins, M. Rhon, D. Delitto, A. Schneider, M. Dearth, C.
Reviewer Name
Emma Velez, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective
The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain with one-year escalation-of-care events including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations.
Methods
This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for low back pain in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios.
Results
Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of one-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of one-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring one-year escalation-of-care events were 50 to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy.
Conclusion
Greater use of passive interventions for low back pain was associated with elevated odds of one-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes.
Impact
Physical therapists should be judicious in use of passive interventions for management of low back pain as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits.
NIH Risk of Bias Tool
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
- Yes
- Was the study population clearly specified and defined?
- Yes
- Was the participation rate of eligible persons at least 50%?
- Yes
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
- Yes
- Was a sample size justification, power description, or variance and effect estimates provided?
- No
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
- Yes
- Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
- Yes
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
- Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Was the exposure(s) assessed more than once over time?
- No
- Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Were the outcome assessors blinded to the exposure status of participants?
- Yes
- Was loss to follow-up after baseline 20% or less?
- Yes
- Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
- Yes
Key Finding #1
36.8% of patients who received only active therapeutic interventions during their time in PT received opioid prescriptions within the following year. The rate of opioid prescription rises as more passive therapies were used in the PT plan of care.
Key Finding #2
Using manual therapy in conjunction with active interventions decreases the likelihood of spinal injections and the incidence of seeking further specialty care for follow-up.
Key Finding #3
The longer a plan of care went on, the more likely it was to see additional passive therapies included in treatment. The rates of opioid prescription of the exclusively passive therapies group and the active therapies plus two or more passive interventions were comparable at 47.8% and 46.4% respectively.
Please provide your summary of the paper
Passive interventions to treat LBP increase the likelihood of long-term adverse events, especially opioid use. This research best supports the use of active therapeutic interventions as a first-line treatment of LBP, with the addition of manual therapy techniques to help further improve health outcomes. Limitations of this study include a narrow population, as all subjects were obtained from the Military Health System. This resulted in 77.2% of participants being male with an average age of 34 years old. The types of therapies studied were determined exclusively by CPT codes. No treatment details were determined or analyzed from the therapists’ session notes.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study further supports the 2021 APTA CPG recommendations for patients with acute, subacute, and chronic LBP that state that these patients should be treated with a combination of exercise and manual therapies. The dosage of these interventions requires clinical reasoning and will vary amongst patients.
