title: Clinical outcomes of early and later physical therapist services for older adults with back pain.
abstract: BACKGROUND
  The timing of physical therapy (PT) services and its association with later function and pain are not clear, especially in older adults.
  
  
  OBJECTIVE
  The purpose of this study was to compare clinical outcomes of patients receiving early or later PT services with those not receiving PT among older adults presenting to primary care for a new visit for back pain.
  
  
  METHODS
  Prospective cohort study using the Back Pain Outcomes Using Longitudinal Data registry.
  
  
  METHODS
  A total of 3,705 adults 65 years and older with a new visit for back pain were included.
  
  
  METHODS
  The outcome measures were Roland-Morris Disability Questionnaire (RMDQ), Pain Numerical Rating Scales, and EuroQol-5D.
  
  
  METHODS
  We studied two phases of PT utilization: early (0-28 days) and later (3-6 months). At baseline, we selected the participants with complete 12 months of patient-reported outcomes and electronic medical record data. Early PT was defined as initiating PT less than or equal to 28 days from the index visit for back pain. The no early PT group consisted of patients with no PT, no injections, no surgery, and no chiropractic within 28 days. We restricted the later phase analysis to patients with pain greater than 2 of 10 and an RMDQ score greater than 4 to create a subsample of patients with continuing clinically important back pain. We defined later PT as initiating PT between 3 and 6 months after the index visit. The no later PT group consisted of patients without any PT during this time. We used propensity score matching followed by multiple linear regression to estimate the mean difference in outcome. Sensitivity analysis examined clinically important change and dose of PT use among the early PT group.
  
  
  RESULTS
  The early PT group had better functional status with an adjusted mean RMDQ of 1.1 points less than the no early PT group (95% confidence interval: -2.2, -0.1) and less back pain of -0.5 (-0.9, -0.1) at 12 months. There was no difference between early PT groups at 3 and 6 months. The odds of a 30% improvement in function or pain were not different between these matched groups at 12 months, but the early PT group had increased odds of a 50% improvement in function at 12 months (odds ratio: 1.58, 95% confidence interval: 1.04, 2.40). There was no difference between later groups at 12 months. Greater dose of PT use within the early PT group was associated with better functional status (p= .01).
  
  
  CONCLUSIONS
  We found that among older adults presenting to their primary care providers for a new episode of back pain, early referral to PT resulted in no or minimal differences in pain, function, or health-related quality at 3, 6, or 12 months compared with a matched group that did not receive early PT. Secondary analysis show that patients initiating early PT may be somewhat more likely to experience 50% improvement in function at 12 months.
authors: Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA. Electronic address: srundell@uw.edu.
authors: Sean D
authors: SD
authors: Rundell
authors: Department of Rehabilitation and Regenerative Medicine, Weill Cornell Medical Center, 525 E 68th St, New York, NY 10021, USA.
authors: Alfred C
authors: AC
authors: Gellhorn
authors: Center for Biomedical Statistics, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA.
authors: Bryan A
authors: BA
authors: Comstock
authors: Center for Biomedical Statistics, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA; Department of Biostatistics, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA.
authors: Patrick J
authors: PJ
authors: Heagerty
authors: Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA.
authors: Janna L
authors: JL
authors: Friedly
authors: Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave NE, Seattle, WA 98105, USA; Department of Radiology, Neurological Surgery, Health Services, Orthopedics and Sports Medicine and Pharmacy, University of Washington, 325 9(th) Ave, Seattle, WA 98104, USA.
authors: Jeffrey G
authors: JG
authors: Jarvik
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001416:Back Pain / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D008297:Male; D026741:Physical Therapy Modalities; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: Back pain; Comparative effectiveness research; Function; Older adults; Outcomes; Physical therapy