A new episode of low back pain can start a surprisingly long chain of medical care. Pain medication may be followed by imaging. Persistent symptoms may lead to specialist visits, injections or additional testing. For some patients, the process becomes considerably more involved than they expected when their back first started hurting.
Research suggests that getting physical therapy involved early may change that trajectory.
Large studies of people with new episodes of low back pain have associated earlier physical therapy with fewer opioid prescriptions, fewer advanced imaging studies, fewer emergency department visits and less use of several other healthcare services later.[1-4]
For people hoping to recover while keeping medical intervention to a reasonable minimum, that makes the timing of physical therapy worth considering.
What Happens When Physical Therapy Comes First?
One particularly large study followed 148,866 adults with a new diagnosis of low back pain for one year.[1] Researchers divided the patients according to how physical therapy entered their care:
Physical therapy was their first point of care
Physical therapy began later
They did not receive physical therapy
The researchers then looked at what happened during the following year, including opioid prescriptions, X-rays, MRI and CT scans, emergency department visits, hospitalization and healthcare costs. Patients who saw a physical therapist first were less likely to receive an opioid prescription, undergo advanced imaging or visit an emergency department.[1] They also had lower outpatient, pharmacy and out-of-pocket costs. Overall healthcare spending was not significantly different, because some spending shifted toward provider-based care such as physical therapy.[1]
Beginning care with physical therapy was associated with less use of several common medical services during the following year.
Earlier Physical Therapy Has Shown Similar Results
That study is not alone.
Researchers examining more than 32,000 people with newly diagnosed low back pain found that patients who began physical therapy within 14 days had lower odds of receiving advanced imaging, spinal injections, surgery, additional physician visits and opioid medication than patients whose physical therapy began later.[2]
Healthcare costs related to low back pain were also about $2,700 lower over the following 18 months among the early physical therapy group.[2]
A systematic review later examined 11 studies dealing with the timing of physical therapy for acute low back pain. Five of six studies comparing early physical therapy with delayed physical therapy found lower subsequent healthcare utilization with earlier care. When researchers combined the available data, early physical therapy was associated with reductions in opioid use, spinal injections and spine surgery.[3]
More recent research continues to find a similar pattern. A large national database study involving approximately one million patients found that physical therapy begun within two weeks of an acute low back pain visit was associated with less use of emergency departments, advanced imaging, pain specialists, orthopedic specialists and epidural steroid injections.[4]
Why Might Starting Earlier Matter?
Physical therapy gives people another way to actively manage back pain early in the process. Treatment may include movement, strengthening, mobility exercises, education and a gradual return to normal activities. A physical therapist can also help determine which movements are safe, which activities may need temporary modification and how quickly activity can be increased.
That guidance can be particularly valuable when pain makes people uncertain about what they should do. For many cases of nonspecific low back pain, staying appropriately active is an important part of recovery. A physical therapist can help turn that general advice into an individualized plan. Earlier care may also give patients an effective treatment option before pain leads them farther down the healthcare pathway.
Fewer Tests Can Sometimes Be Good Medicine
People with significant back pain understandably want to know what is wrong, and an MRI can sound like an obvious next step. Imaging has an important role when a healthcare professional suspects certain serious conditions or when the results are likely to change treatment. Many routine cases of nonspecific low back pain can be evaluated and initially treated without advanced imaging. That helps explain why researchers are interested in MRI and CT use when studying early physical therapy. Lower imaging rates can represent appropriate conservative management when patients are improving and have no indication that advanced testing is needed.
The same principle applies to medications and procedures. The goal is appropriate care for the individual patient, with additional interventions available when they are medically indicated.
What About Pain Medication?
Medication can have an appropriate place in treating low back pain. The research on early physical therapy is interesting because patients who receive physical therapy sooner consistently appear less likely to progress to opioid medication.[1-3] For a patient, the practical takeaway is fairly simple. Physical therapy provides a non-drug treatment option that can begin early, while the problem may still be relatively new. It also gives patients something constructive to do about their condition, rather than simply waiting to see whether the pain becomes severe enough to require another level of care.
Back Pain May Be Easier to Address Before It Becomes a Long Story
Most episodes of low back pain do not require an elaborate medical journey.
When symptoms are appropriate for physical therapy, getting started early may help with recovery while reducing the likelihood of some additional healthcare services later. A physical therapist can evaluate your movement, strength, mobility and symptoms, then help establish a plan for safely returning to the things you need and want to do. Research involving hundreds of thousands of patients suggests that the first steps taken after back pain begins may influence quite a few of the steps that come afterward.[1-4]
Sources
Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM. Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Serv Res. 2018;53(6):4629-4646. doi:10.1111/1475-6773.12984.
Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine. 2012;37(25):2114-2121. doi:10.1097/BRS.0b013e31825d32f5.
Ojha HA, Wyrsta NJ, Davenport TE, Egan WE, Gellhorn AC. Timing of physical therapy initiation for nonsurgical management of musculoskeletal disorders and effects on patient outcomes: a systematic review. J Orthop Sports Phys Ther. 2016;46(2):56-70. [Timing evidence for acute low back pain was subsequently reviewed specifically in the literature.]
Marrache M, Harris AB, Puvanesarajah V, et al. Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a national database. BMC Health Serv Res. 2022.
