title: Timing of Physical Therapy Initiation for Nonsurgical Management of Musculoskeletal Disorders and Effects on Patient Outcomes: A Systematic Review.
abstract: METHODS
  Systematic review.
  
  
  BACKGROUND
  Current US practice guidelines suggest an initial "wait-and-see" approach following onset of musculoskeletal pain, particularly for spinal pain. Several studies suggest that early, compared with delayed, initiation of physical therapy for musculoskeletal conditions may decrease health costs and improve outcomes.
  
  
  OBJECTIVE
  To compare early and delayed initiation of physical therapy for individuals with musculoskeletal conditions and to assess effects on patient-important outcomes and cost.
  
  
  METHODS
  MEDLINE (Ovid), CINAHL (EBSCO), Web of Science, and PEDro were the data sources. We included studies that compared early and delayed initiation of physical therapy for patients with musculoskeletal disorders. Studies in which early and delayed interventions differed were excluded. Two independent reviewers extracted study characteristics and outcomes, and determined eligibility and quality through consensus with a third reviewer. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in summary conclusions. Standardized effect sizes (d) and odds ratios were calculated to assess the effect strength of early versus delayed physical therapy for each included study.
  
  
  RESULTS
  Of the 3855 articles initially screened, 14 studies were included. The majority of articles studied low back pain (only 2 articles studied cervical pain). For spinal pain, there was low-quality evidence that early versus delayed physical therapy was associated with decreased cost and decreased frequency of opioid prescriptions, advanced imaging, and surgeries without compromising patient-important outcomes. One subgroup analyzed showed improved function/disability with early physical therapy in an occupational health setting.
  
  
  CONCLUSIONS
  Although there were consistent results across studies favoring early physical therapy for decreased cost and medical utilization, quality was limited. Preliminary evidence suggests that early physical therapy may decrease cost without compromising outcomes. The primary limitation of the current research on this topic is in study design. Additional high-quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes associated with early initiation of physical therapy.
  
  
  METHODS
  Therapy, level 1a.
authors.forename: Heidi A
authors.initials: HA
authors.lastname: Ojha
authors.forename: Nadia J
authors.initials: NJ
authors.lastname: Wyrsta
authors.forename: Todd E
authors.initials: TE
authors.lastname: Davenport
authors.forename: William E
authors.initials: WE
authors.lastname: Egan
authors.forename: Alfred C
authors.initials: AC
authors.lastname: Gellhorn
mesh_terms: D001416:Back Pain / Q000628:therapy*; D017046:Cost Savings; D017048:Health Care Costs; D006801:Humans; D017116:Low Back Pain / Q000628:therapy; D009140:Musculoskeletal Diseases / Q000628:therapy*; D019547:Neck Pain / Q000628:therapy; D026741:Physical Therapy Modalities / Q000191:economics* / Q000706:statistics & numerical data; D011788:Quality of Life; D012017:Referral and Consultation; D013997:Time Factors; D016896:Treatment Outcome; D014218:Triage
keywords: back pain; cost and cost analysis; early mobilization; health care reform; musculoskeletal diseases; physical therapy; spinal injuries