1. Oh, the Aching Backs!
Low Back Pain:
Eric Robertson, PT,
A Current State ofK.AffairsDPT, OCS
Eric Robertson, PT, DPT, OCS, FAAOMPT
University of Texas at El Paso Continuing Education Series, Spring 2014

2. Our Objectives
 Review current epidemiology of LBP
 Review current clinical guidelines for managing patients with
LBP
 Discuss psychologically informed practice as it relates to
patients with LBP
 Discuss optimal care pathways for patients with LBP

3. Relative Healthcare Costs
Cost in Billions
800
700
600
500
400
300
200
100
0
Cardiovascular
Disease

4. Relative Healthcare Costs
Cost in Billions
350
300
Cardiovascular
Disease
250
200
150
100
50
0
Cancer
Diabetes
LBP
All Arthritis

5. Relative Healthcare Costs
Cost in Billions
800
700
CHRONIC PAIN!
600
500
400
300
200
100
0
Cardiovascular
Disease

6. Which of the following are predictors of LBP?
• Bulging disc without
herniation or root
contact
• Bulging disc without
herniation but with
nerve root contact
• Herniated/Prolapsed
discs
• End plate changes /
Shmorl‘s nodes
• Foraminal or canal
stenosis
Physical findings
/ Imaging
• History of depression
• History of
occupational-related
LBP
• Fearful beliefs about
work as reported in a
survey
Psychosocial
findings

7. How did you do?
 Physically:
 Only disc contact with nerve root has been shown
to be a WEAK predictor of LBP
 Psychosocial:
 Depression, occupational injuries, and fearavoidance are all STRONG predictors of LBP
Implications in terms of pain?

8. Summary of LBP Predictors ?
Physical
Psychosocial

9. Guideline Adherence for LBP
Adherent
Non-adherent

10. Worsening Trends in
the Management
and Treatment of
Back Pain
Malfi et al. JAMA Int Med, 2013
―Despite numerous published
national
guidelines, management of
routine back pain increasingly
has relied on advanced
diagnostic imaging, referrals to
other physicians, and use of
narcotics, with a concomitant
decrease in NSAID or
acetaminophen use and no
change in physical therapy
referrals. With health care costs
soaring, improvements in the
management of back pain
represent an area of potential
cost savings for the health care
system while also improving the
quality of care.‖

11. Things we know
about LBP:
 Incidence
 Second only to the common cold for reasons to see a doctor
 25% of US population has had back pain within last 3 months at
any given time.
 Common Dx in PT Clinics everywhere!
 Prognosis
 Favorable prognosis for simple, acute LBP!
Di Fabio & Boissonault (1998)

12. We have a
problem…
According to
Martin, Deyo et al., (2008
JAMA)
“…spine-related
expenses have risen
exponentially from
1997 – 2005 without
evidence of
improvement of selfassessed health status.”
 Healthcare costs related to low back pain are
climbing
 Outcomes for low back pain are falling

13. Why?
 Cause of LBP is unclear
 Surgical Interventions
 Imaging
 Chronic LBP costs are high as a sub-group

14. Evolution of a Paradigm
 Historically, the diagnosis of LBP has closely
matched the tools with which we have had at
our disposal to examine it.
 1900‘s – Nerve etiologies
 1920‘s – Muscle etiologies
 1950‘s – Bony etiologies (radiographs)
 1980‘s – Disc etiologies (MRI) –
 However, this was discovered in 1938!
Back Pain Diagnoses in the 20th Century, Lutz et al., 2003

15. The percentage of low back pain of a non-specific
nature.

16. So what about that imaging anyway?

17. MRI‘s in Healthy Individuals
% of people
120
100
80
60
40
20
0
All Healthy Sign Anatom
HNP
Facet
Combined

18. Findings on MRI
Do not predict who has LBP in either
the chronic or acute state
• Caragee et al, 2005, 2006; Borenstein et al, 2001; Savage et
al, 1997
Lead to higher rates of surgical
intervention
• Jarvik et al, 2003
Do not predict success or nonsuccess
in rehabilitation or future disability
• Caragee et al, 2005; Kleinsteuck et al, 2006

19. Inappropriate Imaging?
 66% of CT and MRI ordered by primary MD‘s in an
HMO inapprop.
 28-38% of California workers‘ comp. MRI‘s
inappropriate
 Higher use when MD owns imaging facility
 All imaging tests increased 40% from 2000-2003; now
$100 billion/year

20. Pharmaceuticals: 180%
increase!
Martin, Deyo et al, JAMA, 2008

21. Deyo R, AAOMPT 2009

22. Deyo R, AAOMPT 2009

23. Spinal Instability?
 "Spinal instability is routinely given as a diagnosis
to these patients with chronic lower-back pain. It
is a term used to justify an operation. And it‗s a
great diagnosis, because it can't be directly
disproved."

24. Deyo R, AAOMPT

25. Spinal Fusion Surgery
Annual number of spinal-fusion operations rose by 77 percent
between 1996 and 2001. In contrast, TKA and THA increased by 13 to
14 percent during the same interval
Spinal-Fusion Surgery - The Case for Restraint
Deyo RA et al. NEJM. 2004 350, Iss. 7; 722

26. Financial Interests in Spine
Surgery
Pedicle Screws at $13,000 per instrumented
fusion surgery.
• $4 billion per year!
Manufactures acknowledge giving surgeons
millions in royalties, speaking fees, and research
grants.
• On-going government investigation of device makers
Government investigating illegal kickbacks.
• Medtronic paid $40million in settlement
Ableson R, Peterson M; New York Times, 2003

27. Quote:
Dr. Seth Waldman:
 "There will be a lot of people doing the wrong
thing for back pain for a long time, until we finally
figure it out. I just hope that we don't hurt too
many people in the process."

28. Clinical
Guidelines
Diagnosis and Treatment of Low Back Pain: A
Joint Clinical Practice Guideline from the
American College of Physicians and the
American Pain Society. Chou et al., 2007

29. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine

30. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine

31. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine

32. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine

33. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine

34. Clinical Guideline: APS - APC
Chou et al., 2007 Annals of Internal Medicine
•Spinal Manipulation
•Exercise
•Yoga
•Acupuncture
•CBT
•Spinal manipulation

36. 635 Billion Reasons
Or, why addressing chronic pain is in everyone’s best
interest.

37. PAIN
#1 cause of adult
disability in the US

38. PAIN
1 in 6 People live with
chronic pain.

39. PAIN
Total annual direct
costs for pain >$635B.

40. Relative Healthcare Costs
Cost in Billions
350
300
Cardiovascular
Disease
250
200
150
100
50
0
Cancer
Diabetes
LBP
All Arthritis

41. Relative Healthcare Costs
Cost in Billions
800
700
CHRONIC PAIN!
600
500
400
300
200
100
0
Cardiovascular
Disease

42. Summary of LBP Predictors ?
Physical
Psychosocial

43. Implications in terms of pain?
 It might not be as much of a
physical thing as we think!
 We need to consider the
cognitive components!

44. Nociception

45. Nociceptive Input
Mechanical /
Proprioceptive Input
C/Adelta
A-beta
T-Cells
Signal in 2nd order Neurons
dominated by A-beta input

46. Nociception
Noci means danger! Detecting danger.
All the way to thalmus is nociception. The
thalmus is determining what should we tell
the brain
 Nociception can activate protective
responses without us knowing about it…think
withdrawal reflex from a hot stove
Nociception is NOT Pain Perception.

47. The perception of pain
creates pain!
CRPS EXAMPLE Neurology, 2005- touching a
mirror image of the non-painful hand creates
pain and swelling in the painful side.

48. The perception of pain
creates pain!
Also:
 Phantom limb pain
 Severity of Whiplash inversely related to initial
pain perception
 Battlefield injuries: little pain reported
 So…you don‘t need nociception to feel pain.

49. Nociception
Pain
Outside of
awareness
Aware
Input
Small picture
Without emotion
Relatively Simple
Output
Big picture
With emotion
Relatively
Complex
Pain the conscious version of nociception

50. Pain is…
Modern Pain Model: The Neuromatrix Paradigm
 Nociceptive signals are processed in the
brain, mixed with other
sensory, emotional, cognitive, planning, and motor
signals in the brain, and the resultant output is the
pain perception.

51. How do we change pain
perception?
What can we change
 Sensory input from body
 Social work environment
 Expected consequences
 Beliefs, knowledge
What can’t we change
 Previous experience
 Cultural Factors

52. Chronic Pain Models
 We speak of pain processing primarily in terms of
acute pain.
Physical
 Pain that persists beyond nociceptive input is
difficult to understand if you forget that pain is an
output.
 Chronic pain models can influence the way we
treat patients.
Psychosocial

53. Concept: The Body-self
Large loops of neurons between the
thalamus and the cortex which allow parallel
processing and permit:
 An awareness of the body and unique and
separate from the world
 An orientation of the self as a point of awareness

54. Neuromatrix Paradigm
 The collection of structures creating the body-self is
called the neuromatrix.
 The continuous output from this system is a
neurosignature
 The neurosignature is always present and allows us
to perceive normal
 We detect when it‘s abnormal = pain
Melzack, Acta Anaesthesiol Scand 1999; 43: 880–884

55. Neuromatrix Paradigm
 Explains how pain can be felt without
nociception
 Explains chronic pain
 Explains how the brain changes in response to
pain
 Up-regulation, increased receptor fields, more
efficient pain processing

56. Neuromatrix Paradigm
BodySelf
Pain?

57. 57
From: Gifford, LS 1998

58. Identifying Patients at Risk for
Chronic Pain
Originally:
 Waddell‘s Non-organic Signs and Symptoms
Bottom Line:
•None of the non-organic tests served as
effective screening measures to predict
development of chronic LBP
•Alternative screening tools are required
Fritz et al., 2000

59. Identifying Patients at Risk for
Chronic Pain
George & Zepperi, JOSPT, July- 2009
 Fear-avoidance model of musculoskeletal pain
(FAM) (Measured by FABQ)
 Factors influencing pain perception
 Anxiety
 Fear of re-injury
 Catastrophizing
Confrontation
Anxiety
Fear of re-injury
Catastrophizing
Avoidance
Anxiety
Fear of re-injury
Catastrophizing

60. Graded Exposure for Patients
with Chronic Pain
George & Zepperi, JOSPT, July2009

61. L E V E L
P A I N
Injury!
Adapted from Butler & Mosely, 2008, ―Explain Pain‖
H E A L I N G
R E S P ON SE

62. FDAQ – A Measurement
George & Zepperi, JOSPT, July- 2009
George et al., PTJ, July- 2009

63. General Principles
1.
Chronic pain is not a local anatomical problem.
2. Pain perception influenced by common psychological
conditions (FAB, depression).

64. General Principles
3. True psychogenic causes of pain are so rare as to not even be
discussed much in rehab settings. Most patients we see have a
reason to have pain (i.e. injury) and it is the processing of the
pain that is altered.
4. Overt malingering is rare and cannot be detected by physical
therapists (i.e. variation in maximum effort does not equal lack
of effort).

65. General Principles
5. Graded approaches are a good way for PT's to incorporate
cognitive-behavioral principles. The key is to focus on activity
tolerance, NOT pain reduction.
6. If you are seeing a lot of chronic pain, consider a
multidisciplinary approach, as that is where the evidence points
to increased effectiveness.

66. Establishing a Baseline
Therapist: ‗How long can you walk before you flare-up?‘
Patient: ‗I can walk for 30 min but I pay for it the next day‘
Therapist: ‗Can you walk for 20 min without flaring up?‘
Patient: ‗No, but I have‘
Therapist: ‗Can you walk for 10 min without flaring up?‘
Patient: ‗Probably not — definitely not up hills‘
Therapist: ‗5 min on a flat surface?‘
Patient: ‗Probably‘
Therapist: ‗3 min on a flat surface?‘
Patient: ‗Definitely‘

67. Continuous Progression
 ‗every day you do more than you did
yesterday, but not much more‘…at least initially.
 Setting clear measurable goals and objectives!

68. KEY POINTS
 Pain is not nociception
 The representation of the body in the human brain
 The brain changes as the pain persists
 Body-brain is a 2 way street
 Training the brain for people in Pain

69. Patient Education
Perhaps your most powerful analgesic
tool is the ability to educate your patient
about pain physiology.
Physical Therapists
We are the intersection of physiology &
psychology!

70. A = Baseline
Chronic Pain
B = Following
HEP
C = Following
Pain
Education

71. One more thing…
Is spinal manipulation appropriate for people with chronic pain?

72. Response to Thoracic Spine
Manipulation: fMRI
Pre-Manipulation
Post-Manipulation
Sparks et al, JOSPT 2013

73. Timing of Referral and
Adherence to Best Practice
for LBP:
Does It Matter?
John D. Childs, PT, PhD, MBA

74. Non-invasive Interventions for Acute
LBP
Intervention
Net benefit
Level of evidence
Spinal manipulation
Small/Moderate
Fair
Exercise therapy
No benefit
Good
Back schools
Unclear
Poor
Acupuncture
Unclear
Poor
Massage
Unclear
Poor
Interferential therapy, shortwave diathermy, ultrasound,
lumbar supports, TENS
Unclear
Poor

75. Non-invasive interventions for Chronic or Subacute
LBP
Intervention
Net benefit
Level of evidence
Behavioral therapy
Moderate
Good
Exercise therapy
Moderate
Good
Interdisciplinary
rehabilitation
Moderate
Good
Spinal manipulation
Moderate
Good
Acupuncture
Moderate
Fair
Massage
Moderate
Fair
Yoga
Moderate
Fair (for Viniyoga)
Back schools
Small
Fair

76. Arch Intern Med. 2010;170(3):271-277

77. Methods
• Care provided in 3,533 patient visits to GPs for a
new episode of LBP was mapped to key
recommendations in treatment guidelines
• The proportion of patient encounters in which care
arranged by a GP aligned with these key
recommendations was determined for the period
2005 through 2008 and separately for the period
before the release of the local guideline in 2004
(2001-2004)

78. Results
• Despite recommendations to the contrary
• > 25% patients referred for imaging
• Only 20.5% and 17.7% received care limited to advice
and simple analgesics, respectively
• Analgesics provided were typically NSAIDs (37.4%) and opioids
(19.6%)
• This pattern of care was the same in the periods
before and after the release of the local guideline

79. The timing of care
matters.
2011;41(11):838846
Fuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12.

81. Methods
• National 20% sample of CMS outpatient claims
(Medicare)
• Treatment for LBP between 2003-2004 (n=439,195).
• Patients with prior visit for back pain, lumbosacral
injection, or lumbar surgery within the previous
year were excluded
• Referral to physical therapy classified as
• Acute – 0-4 weeks
• -Subacute – 4 weeks – 3 months
• Chronic – 3 months – 1 year

82. Gellhorn et al. 2012; 37: 775 – 782
0.47 (95% CI, 0.44–0.50)
0.46 (95% CI, 0.44–0.49)
0.38 (95% CI, 0.36–0.41)
There was a lower risk of subsequent medical
service among patients who received PT early
after an episode of acute LBP relative to those
who received PT later.

84. Purpose
• Examine the cost implications of the decision to
refer patients with a new episode of LBP from
primary care providers to physical therapy and
examine the influence of the timing of referral
(early vs. delayed) and the content of the care
(adherent vs. non adherent) received by physical
therapists

85. Subjects
SETTING
Data extracted from Mercer
HealthOnline® a database of
members of employeesponsored health plans.

86. Subjects
32,070 patients with a new primary care consultation for
LBP from November 1, 2007 - January 31, 2009.
756.11 Spondylolysis, lumbosacral region
756.11 Spondylolesthesis
722.1 Lumbar disk displacement
722.93 Other disk disorder lumbar region
846.0 Sprain lumbosacral
722.73 Lumbar disk deease with myelopathy
846.8 Sprain – other sacroilliac region
721.3 Lumbosacralspondylosis without myelopathy
846.1 Sprain sacroilliac
,sprain - sacrum
722.52 Lumbar / lumbosacral disc displacement
724.02 Spinal stenosis - lumbar
724.5 Backache, unspecified
847.2 Sprain lumbar region
847.3 sprain other specified sites of sacroiliac region
724.3 Sciatica
724.4 Thoracic or lumbosacral neuritis or radiculitis
724.3 Lumbago

87. Data Abstraction
• Patients meeting definition of new LBP episode visiting a
primary care provider from November 1, 2007 through
January 31, 2009
• Eligible patients had to be continuously eligible within the
database for 6 months before and 18 months after the index
date
• All healthcare visits, procedures, tests, prescription
medications, etc. and associated billed charges
• CPT codes for each visit if patient received physical therapy

88. Inclusion/Exclusion
• Age 18-60 years old at index primary care visit
• No prior spinal surgery
• No evidence of non-musculoskeletal cause of LBP
diagnosis (e.g., infectious process, kidney
stones, gall stones, urinary tract
infection, cancer, osteomyelitis, etc.)

89. Groups
Timing:
1. Early Physical Therapy - 1-14 days from first Dr. visit
(53%)
2. Delayed Physical Therapy - 15-90 days (47%)
Content:
1. Adherent - Active physical therapy based on CPT
codes (22%)
2. Non adherent – Passive physical therapy (78%)

90. Covariates Examined
• Age and gender
• Amount of co-payment for the index visit
• Insurance plan (Point-of-service, Preferred Provider
Organization, Health Maintenance Organization , High
deductible health plan, Other)
• Employment status (Active, Retiree, Long-term
disability, Other)
• Geographic region (Northeast, South, Midwest, West)

91. Comorbidities
• Co-morbid healthcare conditions in 6-month period prior to index date
• Number unique ICD-9 diagnoses recorded in any setting
• Number of unique medications
• If a hospitalization occurred
• If narcotic medications were prescribed
• Total allowed costs for all services (inpatient, outpatient and
prescription)
• Presence of co-morbid health conditions that may influence prognosis
for individuals with LBP
• Mental health conditions (depression, anxiety, bipolar or other
psychotic disorders)
• Concomitant neck or thoracic spine pain
• Fibromyalgia

92. Phase 1: 1st 14 days of Episode of Care
ACTIVE CODES
97110
97350
97535
Therapeutic
Exercise
Therapeutic
Activity
Self Care
Management
Training
PASSIVE CODES
ALLOWED CODES
PT
Evaluation
PT ReEvaluation
97035
Ultrasound
97001
97010
Hot or Cold
Pack
97002
G0283,
97032
Electrical
Stimulation
99070
Miscellaneo
us Supplies
97112
Neuromuscul
ar Re97012
Education
Mechanical
Traction
97750
Physical
Performanc
e
Test/Measu
re
97150
Group
Therapeutic
Procedures
Massage
Therapy
97140
Manual
Therapy
PHASE I
97124
97113
97116
Aquatic
Therapy
with
Exercise
Gait
Training
Therapy

93. Phase 2: >14 days
ACTIVE CODES
97110
97350
97535
PHASE II
PASSIVE CODES
Therapeutic
97140
Exercise
Therapeutic
97035
Activity
Self Care
Management 97010
Training
ALLOWED CODES
Manual
Therapy
97001
Ultrasound
97002
Hot or Cold
Pack
99070
97112
Neuromuscul
G0283,
ar Re97032
Education
Electrical
Stimulation
97750
97150
Group
Therapeutic
Procedures
97012
Mechanical
Traction
97113
97124
Massage
Therapy
97116
PT
Evaluation
PT ReEvaluation
Miscellaneo
us Supplies
Physical
Performanc
e
Test/Measu
re
Aquatic
Therapy
with
Exercise
Gait
Training
Therapy

94. Determination of Adherence
• Number of active and passive CPT codes at each visit within
each phase recorded
• % of active to passive codes calculated as
• Number of active codes/(number of active codes + number of
passive codes) x 100%
• Adherent care defined as % of active to passive codes at
least 75%, with each visit including at least 1 active code
• Comparisons of costs between adherent vs. non-adherent
care

95. All Patients
(n=32,070)
Timing of Physical
Therapy (n=2,077)
Early
Delayed
(n=1,102) (n=975)
Content of Physical
Therapy (n=1,917)
NonAdherent Adherent
(n=413) (n=1504)
Advanced
Imaging (MRI
or CT)
18.9%
29.4%
54.9%
38.7%
43.9%
Physician
Specialist Visits
44.1%
52.6%
81.0%
64.4%
68.8%
Lumbar Spine
Surgery
2.5%
4.7%
9.9%
5.1%
8.1%
Lumbar Spinal
Injections
7.1%
10.1%
21.2%
12.6%
17.8%
Narcotic
49.1%
Medication Use
49.1%
55.3%
49.6%
53.2%
Table 2. Utilization of specific services for low back pain in the 18
month period following the index primary care visit

96. All Patients
(n=32,070)
Timing of Physical
Therapy (n=2,077)
Early
(n=1,102)
Delayed
(n=975)
Content of Physical
Therapy (n=1,917)
NonAdherent
Adherent
(n=413)
(n=1504)
Imaging
Procedures
$291.12
(5.42)
$473.32 $807.20 $513.84 $701.14
(63.92) (42.12) (46.82) (52.32)
Physician Visits
$209.54
(1.48)
$259.62 $411.76 $295.52 $357.15
(9.76)
(11.89) (14.33)
(9.86)
Surgical/
Injection
Procedures
$740.44 $1018.88 $2760.62 $1445.23 $1965.72
(36.84) (170.65) (381.27) (486.37) (229.42)
Inpatient NonSurgical
Procedures
$79.28
(11.13)
$65.00
(30.58)
$231.79 $162.31 $142.99
(64.52) (90.20) (37.81)
Table 3. Costs incurred over the 18 month period following the index
primary care visit. Values represent mean (standard error).

97. All
Patients
(n=32,070)
Timing of Physical
Therapy (n=2,077)
Early
Delayed
(n=1,102) (n=975)
Content of Physical
Therapy (n=1,917)
Adherent Non-Adherent
(n=413)
(n=1504)
Emergency Room
Visits
$19.83
(0.87)
$26.21
(4.89)
$25.22
(4.59)
$24.87
(6.94)
$28.61
(4.36)
Prescription
Medication
$104.23
(3.01)
$80.41
(10.22)
$116.83
(11.27)
$76.43
(9.85)
$98.85
(9.61)
Other LBP-related $437.89 $1225.04 $1531.3 $1090.64
Costs
(8.11) (52.10) (67.01) (89.06)
$1651.73
(53.07)
Total LBP costs
$1882.33 $3148.49 $5884.71 $3608.83
(44.58) (228.90) (429.92) (533.49)
$4946.18
(277.19)
Non-LBP
healthcare costs
$7892.53 $7169.22 $8430.44 $7254.82
(108.75) (472.39) (761.80) (1155.66)
$7511.44
(402.09)
Table 3. Costs incurred over the 18 month period following the index
primary care visit. Values represent mean (standard error).

99. Utilization of Services
Early PT
Delayed PT
53%
81%
49%
55%
10%
21%
4.7%
9.9%
29%
55%

100. Figure 2. Likelihood of receiving specific services during the 18 month
follow-up period based on non adherent physical therapy care.

101. $3,000.00
Total Costs:
$2,500.00
$3148
$5884
$2,000.00
$1,500.00
$1,000.00
$500.00
$0.00
Early PT
Delayed PT

102. Total Costs:
$7,000
$3148
$5884
$6,000
Other LBP-related Costs
$5,000
Prescription Medication
Emergency Room Visits
$4,000
Inpatient Non-Surgical Procedures
Surgical/ Injection Procedures
$3,000
Physician Visits
Imaging Procedures
$2,000
$1,000
$0
Early Physical Therapy
Delayed Physical Therapy

103. Implications of Timing and Quality of Physical
Therapy on Low Back Pain Utilization and Costs in
the Military Health System
John D. Childs, PT, PhD, MBA
Samuel S. Wu, PhD
Eric Robertson, PT, DPT
Forest S. Kim PhD, MHA, MBA
Robert S. Wainner, PT, PhD
Timothy W. Flynn, PT, PhD
Steven Z. George, PT, PhD
Julie M. Fritz, PT, PhD

104. Background
• Back pain & arthritis the most costly conditions requiring rehabilitation
in the U.S.
• Over $200 billion per year, exceeding total costs associated with spinal cord
injury, traumatic brain injury, stroke, multiple sclerosis, and limb loss
• Studies demonstrate that the vast majority of costs are incurred early in
the care process
• Many studies demonstrate lack of adherence to practice guidelines for
managing LBP
• Previous work has demonstrated that timing of referral and adherence
to practice guidelines reduces utilization and costs
• Military Health System offers compelling opportunity to expand this
work because a single payer system

105. Methods
• Extract LBP ICD-9 codes from Jan 1, 2007 through Dec 31, 2009
• Extract full history of these cases from Jan 1, 2006-Dec 31, 2011
• Determine previous medical history for 1-year preceding the index visit
• Conduct 2-year follow-up from index visit
• Newly consulting LBP defined as no claims with a LBP-related
ICD-9 code for 6 months preceding the index date

106. Inclusion/Exclusion
• Age between 18-60 years of age at index date
• Continuously eligible within database 12 months before (to capture comorbidities and previous history) and 24 months after index date
• No co-morbid diagnosis within 4 weeks of index date that could be
nonmusculoskeletal source of LBP (e.g, kidney stones, urinary tract
infection, etc .)
• No prior history of spinal surgery or trauma (ie. fx) based on the
presence of related current procedural terminology (CPT) codes at any
time prior to the index date
• Only the first eligible index date for an individual patient included to
avoid overlap in episodes of care. (ie – individual patients can only
appear once in dataset)

107. Analysis
• Considered 90-day period after the primary care index date to identify PT
utilization
• If a PT visit occurred with a LBP-related ICD-9 during this period, patient
defined as utilizing PT
• Early PT defined as utilizing PT within 14 days from primary care index date
• All PT episodes without a primary care index date (ie, direct access) classified
as early
• Late PT defined as utilizing PT between 15-90 days from index date
• Patients with both PT and chiropractic utilization for LBP excluded
• Adherence determined using the same algorithm previously published
(Fritz, Spine, 2012)
• Controlled for co-morbidities similar to previous research
(Fritz, Spine, 2012)

108. Inclusion and
Exclusion
Criteria
883,969 continuously eligible
patients with primary care for low
back pain.
Age <18 & >60 years
(n=13,992)
Low back pain claim in the
past 6 months (n=38,955)
Possible nonmusculoskeletal low back
pain (n=154,729)
Prior surgery for low back
pain (n=148)
676,145 patients included in
analysis

109. Groups and Demographics
Age (mean, sd)
Gender (% female)
Common Beneficiary Category
Spouse/families
Retired
Other
Active Duty
Timing of PT
Adherence
All
PT Users
Adheren
Patients
Early Delayed
Non‐Adher
(n=158,2
t
(n=676,14
(n=59,4 (n=98,8
ent
(n=23,5
71)
16)
55)
5)
(n=32,750)
50)
33.8
33.3
32.2
34.0
34.8
36.1
(11.2)
(10.5)
(10.4) (10.6) (11.3)
(11.2)
39.10% 34.10% 32.80% 34.90% 41.80% 45.30%
19.80%
10.10%
12.80%
57.30%
14.50% 13.10% 15.30% 20.60%
7.30% 5.80% 8.10% 11.20%
8.80% 8.00% 9.30% 13.20%
69.50% 73.10% 67.20% 55.00%
22.80%
11.70%
14.90%
50.70%

110. Additional Covariates
Timing of PT
All Patients PT Users
Early
Delayed
(n=676,145 (n=158,271
(n=59,416 (n=98,855
)
)
)
)
Number of LBP diagnosis codes
1.5
1.4
1.4
1.4
(mean, sd)
(1.8)
1.5)
(1.2)
(1.6)
Number of prescription
13.6
15.2
12.9
16.5
medications
(10.3)
(10.8)
(9.9)
(11.0)
(mean, sd)
Co‐morbid mental health condition
0.082
0.084
0.078
0.088
Co‐morbid fibromyalgia diagnosis
0.019
0.017
0.016
0.018
Co‐morbid neck/thoracic spine
0.108
0.118
0.129
0.111
condition
Narcotic use prior to index visit 34.10%
35.20%
34.10%
35.90%
Hospitalization prior to index visit 7.20%
7.10%
6.90%
7.20%
Total medical costs prior to index
$3608.26 $3704.36 $3617.90 $3756.35
visit
(8017.10) (7795.80) (8189.26) (7548.91)
(mean, sd)
Adherence
Adherent Non‐Adhere
(n=23,550
nt
)
(n=32,750)
1.5
1.7
(1.7)
(1.9)
15.9
(11.1)
16.4
(11.3)
0.09
0.02
0.088
0.023
0.116
0.142
37.50%
8.40%
$4119.76
(10271.64
)
38.40%
8.50%
$4069.42
(7558.78)

111. Adjusted Odds Ratios & 99% CIs
Advanced Imaging
E vs. D
.47 (.45, .49)
A vs. NA
.68 (.64, .72)
Lumbar surgery
.52 (.47, .56)
.80 (.71, .91)
Spinal injection
.47 (.45, .49)
.78 (.73, .83)
Opioid use
.48 (.47, .50)
.93 (.89, .98)

114. Utilization of Services – Timing of Care
Early
Delayed
Advanced imaging
(MRI or CT)
12%
23%
Lumbar spine
surgery
3%
4%
8%
17%
59%
75%
Lumbar spinal
injections
Opioid medication
use

115. Utilization of Services – Guideline Adherence
Adherent Non-adherent
Advanced
imaging
(MRI or CT)
Lumbar spine
surgery
Lumbar spinal
injections
Opioid
medication
use
23%
30%
2%
4%
14%
18%
71%
73%

116. Utilization of Services – Timing & Guideline
Adherence
E/A E/NA D/A D/NA
Advanced
imaging
(MRI or CT)
Lumbar spine
surgery
Lumbar spinal
injections
Opioid
medication
use
13%
20%
27%
35%
2%
3%
4%
5%
9%
13%
17%
21%
61%
64%
77%
78%

117. Total Costs Incurred Over 2-year
Follow-up
$1,400
$1,200
$859
$1,000
$800
$733
$983
$600
$400
$200
$0
Prescription meds
E/A
E/NA
L/A
L/NA
$1,145

118. Total Costs Incurred Over 2-year
Follow-up
$16,000
$14,000
$12,000
$11,407
$13,030
$10,521
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Inpatient
E/A
E/NA
L/A
L/NA
$13,506

119. Total Costs Incurred Over 2-year
Follow-up
$5,000
$4,340
$4,500
$3,670
$4,000
$3,500
$2,784
$3,000
$2,500
$2,110
$2,000
$1,500
$1,000
$500
$0
Total LBP
E/A
E/NA
L/A
L/NA

120. Total Costs Incurred Over 2-year
Follow-up
$12,000
$10,000
$10,380
$8,470
$8,459
$8,000
$6,000
$4,000
$2,000
$0
Non LBP-related
E/A
E/NA
L/A
L/NA
$10,589

121. Low quality physical
therapy delivered early
is better than current
standard of care for
back pain management
in the U.S.

122. High quality physical
therapy delivered
early is even better

123. Acknowledgements
• This study is funded in part by the following
organizations:
• U.S. Air Force Medical Service Intramural Grant
Program
• Texas State University Faculty Grant

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