Standardizing Management of Patients With Low Back Pain in Primary Care and Physical Therapy

The Institute of Medicine recognizes low back pain (LBP) as a top 15 priority condition,
calling for health care organizations to develop new, evidence-based management strategies.
Most patients with acute LBP are managed in primary care. Primary care management is
characterized by high variability in decision-making, including referral to specialties such
as physical therapy. In the face of this variability it is not surprising that the outcomes
of management for patients with acute LBP are also inconsistent, with a considerable
proportion going on to persistent or recurrent symptoms. Costs associated with patients who
fail to recover quickly or completely can be substantial.

Many patients with acute LBP are referred from primary care to physical therapy. Physical
therapy management of patients with acute LBP is also highly variable in terms of the
interventions used and the outcomes achieved. More effective and standardized management for
patients with acute LBP could impact progression of the condition before the concerns
associated with chronic pain become evident, and are therefore central to reducing costs and
improving outcomes.

Numerous practice guidelines have been developed to attempt to reduce variability and
improve outcomes for patients with acute LBP managed in primary care. Current guidelines
provide little direction for determining the optimal type of patient and timing for referral
to physical therapy, other than a broad recommendation to delay referral for at least a few
weeks. Within physical therapy there is an absence of validated decision-support tools to
reduce inappropriate variation in care and improve outcomes. The Investigators have
developed and validated a clinical decision rule identifying a subgroup of patients with LBP
likely to experience rapid and sustained improvement with a brief, standardized physical
therapy intervention delivered early in the course of care, suggesting it may be more
cost-effective to manage this subgroup with early referral to physical therapy. The impact
of integrating this rule into routine clinical care has not been assessed.

We will conduct a randomized clinical trial examining outcomes and costs associated with
integrating the decision rule into primary care management of patients with LBP. Patients
with LBP who fit the decision rule criteria will be randomized into one of two groups; one
managed with usual care based on current practice guidelines; the other managed based on the
decision rule with early, standardized physical therapy. Patients will be followed for 6
months. Outcomes will include measures of disability, pain, satisfaction, and costs.