From the American Physical Therapy Association (APTA)
Researchers found that physical therapy started within three days of an initial PCP visit improved multiple outcomes.
Sciatica is common among individuals with back pain, but research on what works to alleviate the condition has been limited. That may be changing: A new study of treatment in two Utah health care systems makes the case that early physical therapy can improve outcomes for individuals with recent-onset sciatica, finding notable improvements in self-reported pain and disability of patients who receive early physical therapy compared with patients who received “usual care” in the form of education on back pain and advice to stay active.
Researchers analyzed outcomes data for 110 patients who made an initial visit to one of two health care systems for recent-onset sciatica, defined as sciatica with no treatment from any providers during the preceding six months. Participants were randomized into two groups: one “usual care” group that was given a copy of The Back Book, an educational resource that stresses “the favorable prognosis of LBP and the importance of remaining active and avoiding bedrest,” and a second “early physical therapy” group that was given the book but also referred for four weeks of physical therapy that began within three days of the initial visit. The usual care group also was encouraged to follow up with their primary care provider if they were unsatisfied with progress.
Authors of the study monitored both groups’ scores on the Oswestry Disability Index, at four weeks, six months, and one year after initial visit as a primary outcome. Secondary outcome measures also were used, including the Numeric Pain Rating Scale for low back and leg pain, the Pain Catastrophizing Scale, the Fear-Avoidance Beliefs Questionnaire, and the EuroQol five-dimension tool assessing self-rated overall health.
The mean age of participants was 39 years, with an average symptom duration of 35.8 days. Nearly half — 48.6% — were women, and the total group was overwhelmingly white (83%) and non-Hispanic (86%).
APTA members Julie Fritz, PT, PhD, FAPTA; Elizabeth Lane, PT, DPT, PhD; Gerard Brennan, PT, PhD, FAPTA; John Magel, PT, DSc, PhD; Anne Thackeray, PT, MPH, PhD; Kate Minick, PT, DPT, PhD; and Whitney Meier, PT, DPT, were among the co-authors of the study, published in the Annals of Internal Medicine.
- At four weeks, the early physical therapy group reported statistically significant improvement in Oswestry scores, with an average difference of -8.2 points compared with the usual care group. At six weeks, that difference averaged -5.2, with the gap averaging a -4.8 difference after a year. According to authors, the minimum important difference range in the Oswestry is six to eight points.
- Back pain intensity ratings on the 10-point Numeric Pain Rating Scale were also better for the early physical therapy group, with differences of -1.4 points at four weeks, -0.7 at six months, and -1.0 after a year.
- Other secondary measures also recorded better outcomes for the early physical therapy group, including better scores on the Fear-Avoidance Questionnaires on both work and physical activity, quality-of-life measures, and the pain catastrophizing scale.
- After one year, there were no reported differences between groups in terms of missed work or health care use.
- Early physical therapy patients were more likely to rate their treatments as successful at the four-week and one-year marks.
Why It Matters
According to authors, “the overall prognosis for LBP with sciatica is worse than that for axial LBP,” and yet “there is little research on the effectiveness of common nonpharmacologic management options to inform clinical guidelines.” And even though the guidelines that do exist tend to recommend conservative nonpharmacologic care including exercise, “in practice, some primary care providers use a stepped care approach with an initial period of advice, medication, and self-management, with referral to physical therapy restricted to patients with insufficient improvement.”
In this study, the authors found that early physical therapy “hastened functional improvement, indicating that [it] can be offered to patients as first-line nonpharmacologic care.”
In a video featured in a University of Utah news release on the study, lead author Julie Fritz acknowledges that the results weren’t surprising given what’s already known about physical therapy’s role in treating LBP, but that this “really common” condition hasn’t received a lot of research attention before now.
“We think it’s important that primary care providers and patients understand that physical therapy can help them accelerate their recovery, assist them in regaining their activity levels, and overall help provide assistance in regaining their quality of life when it’s provided early on in an episode of care,” Fritz said.
About the Physical Therapy Provided
Early physical therapy participants were referred to one of nine licensed PTs who received a one-day training session on the study. Although individual PTs were allowed leeway in their approaches to each patient, the program used in the study “used principles of mechanical diagnosis and therapy,” with “movements or positions that centralize or move symptoms toward the spinal midline form[ing] the basis for exercise recommendations.”
Sessions were held twice a week during the first two weeks, followed by one to two sessions in weeks three and four. PTs were instructed to include both exercise and manual therapy in each session, with traction permitted at the discretion of the PT. Participants were instructed to perform home exercises every four to five hours on non-session days.
“Off-protocol” interventions were recorded, including massage in 8.9% of all sessions, dry needling in 1.4% of sessions, and nerve stimulation in one session. More than one-third — 37% — of all early physical therapy participants reported side effects, the most common being increased back pain and stiffness. Thirteen of those side effect incidents were rated as “severe” by participants, but remained after 24 hours in only seven instances.
Keep in Mind …
Authors acknowledge several limitations to the study, including differences in time spent with providers, variations in application of the early physical therapy protocol, lack of blinding of participants or PTs, and racial homogeneity among the participants. The researchers also noted that while their “usual care” protocol required the provision of educational materials, this approach “may not reflect what is typically done in primary care practice.”