Systematic review| Volume 100, ISSUE 7, P1324-1338, July 2019

Download started.


The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review

Published:January 23, 2019DOI:


      • Early physical therapy is within 30 days of the index visit for acute low back pain.
      • Early physical therapy for acute low back pain reduces health services utilization.
      • Early vs delayed physical therapy is more cost effective.
      • Results are mixed for early physical therapy vs usual care.



      To synthesize literature about the effect of early physical therapy (PT) for acute low back pain (LBP) on subsequent health services utilization (HSU), compared to delayed PT or usual care.

      Data Sources

      Electronic databases (MEDLINE, CINAHL, Embase) were searched from their inception to May 2018.

      Study Selection

      Study selection included randomized control trials and prospective and retrospective cohort studies that investigated the association between early PT and HSU compared to delayed PT or usual care. Two independent authors screened titles, abstracts, and full-text articles for inclusion based on eligibility criteria, and a third author resolved discrepancies. Eleven out of 1146 articles were included.

      Data Extraction

      Two independent reviewers extracted data on participants, timing of PT, comparisons to delayed PT or usual care, and downstream HSU, and a third reviewer assessed the information to ensure accuracy and reach consensus. Risk of bias was assessed with the Downs and Black checklist using the same method.

      Data Synthesis

      Eleven studies met eligibility criteria. Early PT is within 30 days of the index visit for acute LBP. Five out of 6 studies that compared early PT to delayed PT found that early PT reduces future HSU. Random effects meta-analysis indicated a significant reduction in opioid use, spine injection, and spine surgery. Five studies compared early PT to usual care and reported mixed results.


      Early PT for acute LBP may reduce HSU, cost, and opioid use, and improve health care efficiency. This review may assist patients, health care providers, health care systems, and third-party payers in making decisions for the treatment of acute LBP.


      List of abbreviations:

      APTA (American Physical Therapy Association), CI (confidence interval), HSU (health services utilization), LBP (low back pain), MRI (magnetic resonance imaging), OR (odds ratio), PT (physical therapy), RCT (randomized control trial)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Global Burden of Disease Study 2013 Collaborators
        Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 386: 743-800
        • Dagenais S.
        • Caro J.
        • Haldeman S.
        A systematic review of low back pain cost of illness studies in the United States and internationally.
        Spine J. 2008; 8: 8-20
        • Martin B.I.
        • Deyo R.A.
        • Mirza S.K.
        • et al.
        Expenditures and health status among adults with back and neck problems.
        JAMA. 2008; 299: 656-664
        • Qaseem A.
        • Wilt T.J.
        • McLean R.M.
        • Forciea M.A.
        Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2017; 166: 514-530
        • Kent P.M.
        • Keating J.L.
        The epidemiology of low back pain in primary care.
        Chiropr Osteopat. 2005; 13: 13
        • Casazza B.A.
        Diagnosis and treatment of acute low back pain.
        Am Fam Physician. 2012; 85: 343-350
        • Delitto A.
        • George S.Z.
        • Van Dillen L.R.
        • et al.
        Low back pain.
        J Orthop Sports Phys Ther. 2012; 42: A1-A57
        • Fritz J.M.
        • Cleland J.A.
        • Speckman M.
        • Brennan G.P.
        • Hunter S.J.
        Physical therapy for acute low back pain: associations with subsequent healthcare costs.
        Spine (Phila Pa 1976). 2008; 33: 1800-1805
        • Gellhorn A.C.
        • Chan L.
        • Martin B.
        • Friedly J.
        Management patterns in acute low back pain: the role of physical therapy.
        Spine (Phila Pa 1976). 2012; 37: 775-782
        • Chou R.
        • Qaseem A.
        • Snow V.
        • et al.
        Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Childs J.D.
        • Fritz J.M.
        • Wu S.S.
        • et al.
        Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.
        BMC Health Serv Res. 2015; 15: 150
        • Fritz J.M.
        • Childs J.D.
        • Wainner R.S.
        • Flynn T.W.
        Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.
        Spine (Phila Pa 1976). 2012; 37: 2114-2121
        • Fritz J.M.
        • Magel J.S.
        • McFadden M.
        • et al.
        Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial.
        JAMA. 2015; 314: 1459-1467
        • Zigenfus G.C.
        • Yin J.
        • Giang G.M.
        • Fogarty W.T.
        Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders.
        J Occup Environ Med. 2000; 42: 35-39
        • Liu X.
        • Hanney W.J.
        • Masaracchio M.
        • et al.
        Immediate physical therapy initiation in patients with acute low back pain is associated with a reduction in downstream health care utilization and costs.
        Phys Ther. 2018; 98: 336-347
        • The Moran Company
        Initial treatment intervention and average total Medicare A/B costs for FFS beneficiaries with an incident low back pain (lumbago) diagnosis in CY 2014.
        (Available at:) (Accessed May 1, 2018)
        • Ojha H.A.
        • Wyrsta N.J.
        • Davenport T.E.
        • Egan W.E.
        • Gellhorn A.C.
        Timing of physical therapy Initiation for nonsurgical management of musculoskeletal disorders and effects on patient outcomes: a systematic review.
        J Orthop Sports Phys Ther. 2016; 46: 56-70
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Ojha H.A.
        • Snyder R.S.
        • Davenport T.E.
        Direct access compared with referred physical therapy episodes of care: a systematic review.
        Phys Ther. 2014; 94: 14-30
        • Nordeman L.
        • Nilsson B.
        • Moller M.
        • Gunnarsson R.
        Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial.
        Clin J Pain. 2006; 22: 505-511
        • Fritz J.M.
        • Kim J.
        • Thackeray A.
        • Dorius J.
        Use of physical therapy for low back pain by Medicaid enrollees.
        Phys Ther. 2015; 95: 1668-1679
        • Fritz J.M.
        • Kim M.
        • Magel J.S.
        • Asche C.V.
        Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial.
        Spine (Phila Pa 1976). 2017; 42: 285-290
        • Karvelas D.A.
        • Rundell S.D.
        • Friedly J.L.
        • et al.
        Subsequent health-care utilization associated with early physical therapy for new episodes of low back pain in older adults.
        Spine J. 2017; 17: 380-389
        • Rhon D.
        • Miller R.
        • Fritz J.
        Effectiveness and downstream healthcare utilization for patients that received early physical therapy versus usual care for low back pain: a randomized clinical trial.
        Spine (Phila Pa 1976). 2018; 43: 1313-1321
        • Thackeray A.
        • Hess R.
        • Dorius J.
        • Brodke D.
        • Fritz J.
        Relationship of opioid prescriptions to physical therapy referral and participation for Medicaid patients with new-onset low back pain.
        J Am Board Fam Med. 2017; 30: 784-794
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Fritz J.M.
        • Brennan G.P.
        • Hunter S.J.
        Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges.
        Health Serv Res. 2015; 50: 1927-1940
        • Frogner B.K.
        • Harwood K.
        • Andrilla C.H.A.
        • Schwartz M.
        • Pines J.M.
        Physical therapy as the first point of care to treat low back pain: an instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs.
        Health Serv Res. 2018; 53: 4629-4646
        • Plenet A.
        • Gourmelen J.
        • Chastang J.F.
        • Ozguler A.
        • Lanoe J.L.
        • Leclerc A.
        Seeking care for lower back pain in the French population aged from 30 to 69: the results of the 2002-2003 Decennale Sante survey.
        Ann Phys Rehabil Med. 2010; 53 (231-8): 224-231
        • Walker B.F.
        • Muller R.
        • Grant W.D.
        Low back pain in Australian adults. health provider utilization and care seeking.
        J Manipulative Physiol Ther. 2004; 27: 327-335
        • Carey T.S.
        • Evans A.T.
        • Hadler N.M.
        • et al.
        Acute severe low back pain. A population-based study of prevalence and care-seeking.
        Spine (Phila Pa 1976). 1996; 21: 339-344
        • Mortimer M.
        • Ahlberg G.
        • MUSIC-Norrtälje Study Group
        To seek or not to seek? Care-seeking behaviour among people with low-back pain.
        Scand J Public Health. 2003; 31: 194-203
        • Chevan J.
        • Riddle D.L.
        Factors associated with care seeking from physicians, physical therapists, or chiropractors by persons with spinal pain: a population-based study.
        J Orthop Sports Phys Ther. 2011; 41: 467-476
        • Hoy D.
        • Brooks P.
        • Blyth F.
        • Buchbinder R.
        The epidemiology of low back pain.
        Best Pract Res Clin Rheumatol. 2010; 24: 769-781
        • Hestbaek L.
        • Leboeuf-Yde C.
        • Manniche C.
        Low back pain: what is the long-term course? A review of studies of general patient populations.
        Eur Spine J. 2003; 12: 149-165
        • Pengel L.H.
        • Herbert R.D.
        • Maher C.G.
        • Refshauge K.M.
        Acute low back pain: systematic review of its prognosis.
        BMJ. 2003; 327: 323
        • Ehrmann-Feldman D.
        • Rossignol M.
        • Abenhaim L.
        • Gobeille D.
        Physician referral to physical therapy in a cohort of workers compensated for low back pain.
        Phys Ther. 1996; 76 ([discussion: 156-7]): 150-156
        • Fritz J.M.
        • King J.B.
        • McAdams-Marx C.
        Associations between early care decisions and the risk for long-term opioid use for patients with low back pain with a new physician consultation and initiation of opioid therapy.
        Clin J Pain. 2018; 34: 552-558
        • Wong A.Y.
        • Parent E.C.
        • Dhillon S.S.
        • Prasad N.
        • Kawchuk G.N.
        Do participants with low back pain who respond to spinal manipulative therapy differ biomechanically from nonresponders, untreated controls or asymptomatic controls?.
        Spine (Phila Pa 1976). 2015; 40: 1329-1337