Physical Therapy for Low Back Pain: What Is It, and When Do We Offer It to Patients?

I enjoyed reading Dr. Carey et al's editorial in response to Dr. Foster's recent impact analysis of the STarT trial. I continue to be interested as a researcher and clinician how we can best determine which patients benefit most from accessing physical therapy (PT) services. The current standard of care for low back pain (LBP) in the U.S. is utterly broken in my opinion, with far too many patients accessing high cost services too early in the care process (drugs, imaging, injection, surgery, etc.). As long as our current fee-for-service model remains the mainstay, we can surely count on the axiom "what gets paid, gets done" to hold true. Given some of our work looking at what happens when patients are referred early to physical therapy (<2 weeks versus later >2 weeks), I continue to be impressed by the extent to which early access to PT results in huge "downstream" cost savings attributable to less subsequent healthcare utilization, lower rates of surgery, imaging, etc. What is even more interesting is that these savings are realized even when the quality of the PT care is mediocre. There seems to be a protective effect against all sorts of expensive and likely unnecessary health care utilization simply by the patient being steered to PT early on in the course of care. It seems that re-aligning the process of care (even more than improving quality) is where the majority of the potential innovation should occur.

In other words, how do we figure out how to direct the appropriate patients with LBP to see PT. Recommending that everyone with LBP see a physical therapist, although a simple approach, will likely only drive up costs further. Clearly that doesn't seem to be a logical solution, which is why the STarT criteria are so compelling. These criteria offer a pragmatic approach that directs the right patients with LBP to PT, mitigating unnecessary utilization in patients whose risk for chronicity is rather low (and likely don't need subsequent health care services for their LBP of any type, physical therapy or otherwise). Time will tell, but my sense is that the effects of implementing the STarT criteria in the U.S. will be magnified compared to the effects in the UK given the over consumption of health care in general in the U.S. In other words, there is simply more room for improvement so the incremental opportunity to make a difference is much bigger in my opinion.

I applaud Dr. Foster and her team and thank Drs. Carey and Freburger for adding their perspective on the potential for implementing the STarT criteria in the U.S. I hope we soon get busy accepting the STarT criteria as standard of care in the U.S.

John D. Childs, PT, PhD, MBA, Associate Professor, US Army-Baylor Doctoral Program in Physical Therapy

Competing interests: None declared