Early Physical Therapy Referral for Low Back Pain, Sciatica, and Lumbar Radiculopathy



Low back pain affects nearly 80% of adults throughout their lifetime, with over 10% of the population being disabled due to the condition (2,3). This ailment may also be associated with sciatica and/or lumbar radiculopathy in 18% of cases (10). For successful treatment, a patient should visit their primary care physician for appropriate referral. Primary care physicians may refer a patient to a physical therapist, neurologist, orthopedic surgeon, and/or pain specialist. The purpose of this article is to shed light on the importance of early physical therapy intervention as opposed to different methods of treatment.


In the past, physical therapy interventions for injuries included passive treatments with a focus on pain relief. This passive treatment method has been deemed unsuccessful for long-term pain relief. However, with a focus on early intervention and functional restoration, there has been a quicker return to work with injured patients (3). Physical therapy has evolved to include this approach, with an emphasis on progressive monitored exercise that aims to maximize function, plan return to work, reduce disability, and limit injury recurrence (14).

Referral to physical therapy is essential, but timing of referral is just as crucial. One study shows that referral to physical therapy within one month of a back injury resulted in return to work within 60 days, while referral to physical therapy after one month of a back injury resulted in absence from work for over 60 days. This study also showed that there are reduced physician visits, shorter duration of symptoms, shorter duration of restricted work, and less days away from work in a group with early physical therapy intervention after an initial low back injury (5). Another study showed that early active interventions by physicians and physical therapists resulted in reduced work absence and reduced risk of developing chronic pain in patients with acute musculoskeletal pain (9). A final study showed that early physical therapy intervention resulted in a 60% decrease of low back pain-related costs and lower health-care utilization (4). While these studies show substantial benefit of early physical therapy intervention, some studies showed no benefit in early intervention at all. However, there are limitations to these results, including no specific time frame for referral, with patients starting treatment anywhere from 2 days to 70 days after an injury (11).





Early physical therapy referral for sciatica and lumbar radiculopathy has shown to have similar benefits. One study shows that early physical therapy referral from primary care physicians for patients with sciatica led to greater improvements at 6-month follow-up. Those treated with early physical therapy for sciatica were more likely to report treatment success at one-year follow-up (7). There is moderate support of physical therapy spinal manipulation for symptom relief in patients with acute lumbar radiculopathy (6). Spinal manipulation was shown to be pain relieving in both acute and chronic lumbar radiculopathy, however there was more significant pain relief in the former (11). Dry needling in patients with acute lumbar radicular pain found improved pain and improved pain threshold (13). There is also evidence supporting physical therapy treatments such as stabilization exercises, manual and mechanical traction, and electrotherapy for pain relief in patients with acute lumbar radiculopathy (8). Physical therapists will also educate patients on their condition for a better understanding of their diagnosis and prognosis, along with education on activity modifications to reduce symptoms. Bed rest should be avoided in both sciatica and lumbar radiculopathy. The key to both of these conditions, and the reason that early physical therapy referral is vital, is graded exercise and patient education. Manual therapy has been shown to improve symptom relief, allowing a patient to perform graded exercise with decreased pain.

These findings suggest early active intervention for low back pain may lead to reduced medical costs, reduced disability, a decreased risk of chronic pain, fewer days of restricted work, as well as less days away from work. Sciatica and lumbar radiculopathy should be treated with early physical therapy referral, including manual therapy, to improve symptoms and limit disability. A team of professionals, including your primary care physician, physical therapist, neurologist, orthopedic surgeon, and pain specialist will ensure successful comprehensive treatment.



References:

1. Balagué F1, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.


2. Casiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK538173/ (last accessed 21.1.2020)


3. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998; 339:1021–1029.


4. 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 15, 150 (2015). https://doi.org/10.1186/s12913-015-0830-3


5. Ehrmann-Feldman D, Rossignol M, Abenhaim L, Gobeille D. Physician referral physical therapy in a cohort of workers compensated for low back pain. Phys Ther. 1996; 76:151–157.


6. Farny Juliana et al.; Anatomy of the posterior approach to the lumbar plexus block; Canadian Journal of Anaesthesia; p 480-485; 1994


7. Fritz, Julie M., et al. "Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica." Annals of Internal Medicine, Oct. 2020, doi:https://doi.org/10.7326/M20-4187.


8. Kennedy DJ et al. The role of core stabilization in lumbosacral radiculopathy. Phys Med Rehabil Clin N Am. 2011 Feb


9. Linton SJ, Hellsing AL, Anderson D. A controlled study of the effects of an early intervention on acute musculoskeletal pain problems. Pain. 1993; 54:353–359.


10. O'Sullivan, P. and Lin, I. Acute low back pain Beyond drug therapies. Pain Management Today, 2014, 1(1):8-14


11. Sinclair S, Hogg-Johnson S, Mondloch MV, Shields SA. The effectiveness of an early active intervention program for workers with soft-tissue injuries. Spine. 1997; 22:2919–2931.


12. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin 2007; 25(2): 387–405.


13. Winnie A. P. et al.;The inguinal paravascular technic of lumbar plexus anesthesia: the 3 in 1 block; Anesthesia & Analgesia; p989-996; 1973 LOE: 5


14. Zigenfus, Gary C. MSPT; Yin, Jiahong BS, PhD; Giang, Geneva M. MBA; Fogarty, W. Tom MD Effectiveness of Early Physical Therapy in the Treatment of Acute Low Back Musculoskeletal Disorders, Journal of Occupational and Environmental Medicine: January 2000 - Volume 42 - Issue 1 - p 35


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