Paper
Early Referral to Physical Therapy: A Reasonable Choice for Primary Care Patients With Sciatica
Published Oct 6, 2020 · N. Foster, M. Reddington
Annals of Internal Medicine
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Abstract
Care Patients With Sciatica S involves pain that radiates down the leg, often with a sharp, shooting or burning quality, usually due to disk herniation. Although common in primary care, the evidence to inform clinical decisions in this setting is limited; most studies are done in hospital settings or specialist spine centers. Some patients recover without much treatment, whereas others form distinct clusters with high levels of pain and disability (1, 2). Some patients may benefit from conservative management, such as physical therapy, or from consideration of more invasive treatments, such as injection therapy or disk surgery. However, decision making about early referral is particularly challenging given the limited and conflicting evidence base on treatment effectiveness (3) and studies showing that magnetic resonance imaging findings are unhelpful in patient selection for different treatments (4). Previous economic models conclude that stepped-care approaches are likely to be more cost-effective than strategies that involve direct referral for disk surgery (5). A recent primary care trial showed no significant benefit from a stratified-care approach that included fast-tracking a subgroup of patients for magnetic resonance imaging and consideration for invasive treatments (6). One of the few factors shown to independently predict poor outcomes in sciatica in primary care is leg pain duration (7)—patients with longer durations of leg pain have worse pain and disability outcomes over time—thus underlining the importance of early decision making. The randomized trial by Fritz and colleagues (8) is one of the few trials to focus on patients with sciatica consulting in primary care, addressing the question of comparable effectiveness of adding physical therapy for all patients with pain durations of less than 90 days to standardized advice and education. All patients had a primary care visit and could receive medications or imaging referrals at the discretion of the primary care provider. Potential participants were identified after their primary care visit using electronic health records and then invited into the trial. All received standardized advice and education (a copy of the patient booklet The Back Book with key messages reinforced by a research assistant) before random assignment to either no further intervention (other than usual follow-up with their primary care provider) or a program of physical therapy. The program comprised 6 to 8 treatment sessions over 4 weeks and included exercises using principles of mechanical diagnosis and therapy, regular home exercises, and additional options of manual therapy (mobilization or high-velocity thrust manipulation) or traction. The primary outcome of patient self-reported disability was assessed using the Oswestry Disability Index (scores range from 0 to 100) at 6 months, and the trial was powered to be able to detect a moderate between-group effect size (standardized mean difference of 0.4). Other key outcomes were captured at 4-week and 1-year follow-ups. The trial was prospectively registered, had high retention rates, and had clear approaches to primary and sensitivity analyses. The results from the primary outcome and several secondary outcomes (although, interestingly, not leg pain intensity) favored referral to physical therapy, and whereas the mean point estimate of the betweengroup difference in the Oswestry Disability Index was a little lower (at 5.4) than the most commonly reported minimum clinically important differences, the 95% CIs included or were close to these minimum clinically important differences. Sensitivity analyses did not alter the conclusions. Close to double the proportion of participants self-rated treatment success in those allocated to early physical therapy compared with those allocated to standardized advice and education (45.2% vs. 27.6% at 1 year). Interestingly, neither further health care use nor work loss were different between the trial groups. Whereas the former could be explained by the trial design (patients were identified after their primary care consultation and, therefore, the clinical decisions made by their primary care provider were unlikely to have been influenced by the trial), the latter is more difficult to explain. It may be attributable to the characteristics of the sample—on average, they were younger, with less disability, less leg pain, and higher quality of life compared with other primary care sciatica trials (6). The average benefit of early referral to physical therapy was, overall, rather modest. Of note, fewer than half of all patients still could not self-rate their treatment as a success by 12 months, highlighting the need to continue to develop and test more effective approaches to sciatica management. We cannot rule out that the average, modest, but nevertheless beneficial effects seen in this trial may be attributed to the increased attention and interaction with a caring health professional (a physical therapist) who provided legitimization of the patients' symptoms rather than the specifics of the intervention program itself (the exercise, manual therapy, or traction). The authors rightly acknowledge this. It is possible that patients randomly allocated to the control group felt like they were not really getting much from their trial participation. Nor are we given information with which to compare the cost-effectiveness of the addition of early referral to physical therapy. Although disability was, on average, better in the group referred early to physical therapy, the lack of effect on further health care use or workdays lost could mean that the additional cost of referring all patients with acute or subacute sciatica for early physical therapy would still be difficult to justify in
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