Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica : A Randomized Controlled Trial

Abstract

Background: Few studies have examined primary care management for acute sciatica, including referral to physical therapy.

Objective: To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica.

Design: Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350).

Setting: 2 health care systems in Salt Lake City, Utah.

Patients: 220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation.

Intervention: All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy.

Measurements: The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays.

Results: Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, -5.4 points [95% CI, -9.4 to -1.3 points]; P = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, -4.8 points [CI, -8.9 to -0.7 points]) and back pain intensity (relative difference, -1.0 points [CI, -1.6 to -0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays.

Limitation: The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined.

Conclusion: Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC.

Primary funding source: Agency for Healthcare Research and Quality.

Figure 1.

Enrollment and assessments, by treatment group.

Figure 2.

Time course of back pain–related disability, back pain intensity, and leg pain intensity, by treatment group. EPT = early physical therapy; UC = usual care. Top. The mean back pain–related disability scores were measured using the Oswestry Disability Index. Scores range from 0 to 100, with higher scores representing greater disability. Middle. Mean score for back pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Bottom. Mean score for leg pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Mean differences were calculated with linear mixed models. Error bars indicate 95% CIs. Raw means are provided at baseline.

Figure 2.

Time course of back pain–related disability, back pain intensity, and leg pain intensity, by treatment group. EPT = early physical therapy; UC = usual care. Top. The mean back pain–related disability scores were measured using the Oswestry Disability Index. Scores range from 0 to 100, with higher scores representing greater disability. Middle. Mean score for back pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Bottom. Mean score for leg pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Mean differences were calculated with linear mixed models. Error bars indicate 95% CIs. Raw means are provided at baseline.

Figure 2.

Time course of back pain–related disability, back pain intensity, and leg pain intensity, by treatment group. EPT = early physical therapy; UC = usual care. Top. The mean back pain–related disability scores were measured using the Oswestry Disability Index. Scores range from 0 to 100, with higher scores representing greater disability. Middle. Mean score for back pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Bottom. Mean score for leg pain intensity. Scores range from 0 to 10, with 0 indicating no pain and 10 indicating worst imaginable pain. Mean differences were calculated with linear mixed models. Error bars indicate 95% CIs. Raw means are provided at baseline.