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The Spine Blog

Sunday, September 30, 2018

The effectiveness of PT for acute LBP in a military population

Physical therapy (PT) has been a mainstay in the treatment of acute low back pain (LBP), along with admonitions to avoid bedrest, anti-inflammatory medication, and education about the benign natural history of the condition. Level 1 data on these interventions are sparse, and, given the high incidence of acute LBP, evidence should exist to guide treatment as the potential societal cost of these interventions is relatively high. In order to address this, Dr. Rhon and colleagues performed an RCT comparing usual care to early physical therapy for the treatment of acute LBP in an active military population. They enrolled 119 patients who all attended a 20 minute educational class about acute LBP and were then randomized to receive usual care (UC) or 8 PT sessions over the next 3 weeks. The primary outcome measure was the Oswestry Disability Index (ODI) score at one year, and they also recorded numeric pain rating scales and healthcare related costs. The average age was 27, and 85% of patients were male. The only patient reported outcome that was significantly different was the 4 week ODI score, which was 4 points better in the PT group. The PT group spent about $1,000 more on LBP related treatments, though overall one-year healthcare costs were similar for the two groups. The UC group spent about $700 more on non-LBP related care.

The authors have done a nice job performing an RCT to study the effect of early PT on acute LBP outcomes. Their results suggest that early PT does not yield any long-term advantage compared to UC in active military patients with acute LBP, and the short-term advantage is likely clinically insignificant. An important consideration when interpreting these data is the population to which they apply:  active military patients with acute LBP. Randomized trials offer the benefit of eliminating sources of bias and confounding, however, they tend to answer very narrow questions in very specific populations. These results are not generalizable to the non-military population, to patients with chronic LBP, or to those with radiculopathy or claudication. The other major limitation of this study is that it was likely underpowered according to the authors’ power analysis, however, there were no trends indicating that PT likely resulted in a clinically significant long-term benefit compared to UC. The most important finding from this trial is the benign natural history of acute LBP in a young, fit military population. These patients should be reassured that they will most likely get better regardless of treatment received, and expensive or time-consuming early treatment is probably not necessary. For the minority whose symptoms persist, more intensive treatment can be started.

Please read Dr. Rhon’s article on this topic in the October 1 issue. Does this change your view of the role of PT in acute LBP? Let us know by leaving a comment on The Spine Blog.

Adam Pearson, MD, MS

Associate Web Editor