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Test yourself: The appropriate use of physical therapy in low back pain

Over 90% of patients with uncomplicated acute back pain improve satisfactorily within six weeks with

June 20, 2018
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Tom Denberg, MD, Senior Medical Director

Over 90% of patients with uncomplicated acute back pain improve satisfactorily within six weeks without any treatment at all (University of Michigan, Michigan Medicine Quality Department, Guidelines for Clinical Care: Acute Low Back Pain, pg. 1). Nonetheless, physical therapy (PT) is commonly prescribed for episodes of low back pain. Therapeutic exercise, the cornerstone of PT, emphasizes patient responsibility and exertional body movements aimed at restoring physical function, including strength and range of motion. While guiding patients through exercises in the clinic, physical therapists can teach patients how to do the exercises by themselves at home. In addition, they can educate patients about the nature of low back pain, how to prevent future injury, and how to have reasonable expectations (e.g., complete pain relief is often unrealistic, and outcomes are better when opioids are avoided and when patients return to at least modified work duty as soon as is tolerated). Finally, physical therapists can reassure patients, build their confidence, and offer care and concern.

Some patients derive significant benefit from PT. On the other hand, some do not benefit at all or only benefit for a limited period of time. Thus, the value of PT for the individual patient should be assessed at regular intervals and continued only when there is evidence of ongoing, specific and measurable functional gain. Physical therapists typically assess functional gain in terms of improvements in strength, range of motion, endurance, or physical performance (e.g., lifting, pushing, and activities of daily living, such as putting on one’s socks or walking).

The Division of Worker’s Compensation (DOWC) Low Back Pain (LBP) Medical Treatment Guidelines (MTG) specify “time-to-produce-effect” intervals that include six sessions of PT to observe an initial response (pg. 84). If no meaningful functional gain is observed at this point, PT should be discontinued. If there is functional gain, then six more sessions can be offered. At the end of this second period, additional meaningful functional gain must be demonstrated before more PT is offered. PT that continues without evidence of functional gain represents excessive treatment that can contribute to poor outcomes and avoidable cost. Finally, only a judicious number of in-clinic PT sessions should be required for patient instruction; afterward, benefits should be sustainable through a home-based program.

Please consider the following three excerpts of medical record documentation. With each, identify as many issues as you can.

Physical therapy documentation #1

Baseline examVisit #13 exam (week 8)Gait/Locomotion: L antalgic and decreased trunk mobilityGait/Locomotion: L antalgic and decreased trunk mobilityPalpation: Moderate spasm L lumbar paraspinalsPalpation: Moderate spasm L lumbar paraspinals

Reflex/Sensory: Normal in all dermatomes

Reflex/Sensory: Normal in all dermatomes

// Neither at the baseline exam nor at the week 8 exam is there quantified or graded measurement of physical function (e.g., flexion and extension range of motion in degrees or strength based on ability to lift specific amounts of weight). As a consequence, it is impossible to objectively determine whether the patient is realizing functional gain.

// The exam findings are identical over a two-month period. This raises questions about whether medical record elements have been “cut-and-pasted” and whether follow-up physical exams have even been performed. If taken at face value, the identicalness of the physical exams is a reason to conclude that there has been no functional gain.

// Because PT is continuing without evidence of functional gain past an initial, and possibly a subsequent, “time-to-produce-effect” interval, its use is excessive (DOWC LBP MTG, pg. 84). Ongoing but unhelpful PT may delay the resolution of a patient’s injury, interfere with trying a different form of treatment that might actually help, and distract from identifying and addressing critical psychosocial factors that often contribute to a patient’s delayed recovery.

Physical therapy documentation #2

AssessmentTreatment emphasis to focus on muscle function improvement and pain relief.

// The goal of care is extremely vague (“muscle function improvement”). Goals should be specific and quantifiable.

// The emphasis on pain relief is inappropriate. Maximization of physical function, not pain relief, is the proper primary goal of therapy (DOWC LBP MTG, pg. 74). Complete pain relief is often unfeasible. Likewise, the persistence of pain by itself is not a sufficient reason to continue with physical therapy. Pain is a pertinent aspect of functional status only when it is meaningfully correlated with objective physical findings or test results (DOWC LBP MTG, pgs. 2–3). Physical therapists and physicians who emphasize the goal of complete pain relief can nurture inappropriate patient expectations, thereby contributing to delayed recovery.

Authorized treating physician (ATP) documentation for a 22 yo healthy male, no medical history, mechanical back sprain, no red flags #3

Baseline visitWeek 9 visitSubjective: Significant pain with bending or lifting. No radicular symptoms.Subjective: Continued discomfort, intermittent spasm.Exam: Inspection – nl spine curvature; palpation – no tenderness; straight leg raising test – negative; motor – 5/5 bilaterally; sensory – nl bilaterally; gait – nlExam: Inspection – nl spine curvature; palpation – no tenderness; straight leg raising test – negative; motor – 5/5 bilaterally; sensory – nl bilaterally; gait – nlAssessment/Plan: Acute back pain. Physical therapy 3x/week for 6 weeks. Ibuprofen 600mg prn, Tramadol 25mg 3x/day. Full work restriction. Anticipate return to work 6 weeks.Assessment/Plan: Low back pain. Continue physical therapy. Ibuprofen, Tramadol.  Anticipate MMI and return to work in 3 weeks.

// The baseline physical exam is normal, and its documentation looks like unmodified text from an EHR template. There is no functional assessment (e.g., of strength and range of motion). Pain is the only abnormal finding but is not a valid indicator of functional ability by itself. Without a credible functional assessment around the time of injury, there is no baseline measurement against which to compare progress.

// The provider has prescribed 18 sessions of PT, which is excessive. Six sessions is an initial “time-to-produce-effect” quantity, after which the patient should be reassessed and functional gain demonstrated before more PT is prescribed.

// As a side note, Tramadol, an addictive synthetic opioid, is prescribed without an apparent limitation in days’ supply. This is contrary to the DOWC Chronic Pain Disorder Medical Treatment Guideline, which recommends a limit of seven days of Tramadol use (pg. 100). Also, Tramadol is continued well beyond the acute phase of injury.

// By week nine, a large amount of PT has been completed, but there is no evidence of functional gain. PT should have been discontinued after six sessions.

// After more than two months, the patient is not making expected progress, and his pain is disproportionate to his persistently normal physical exam. There is no indication that a psychosocial assessment has been performed and used to inform the treatment plan. A psychosocial assessment, which can and usually should be performed by the primary care provider without referral to a psychologist or psychiatrist, would elucidate a history of substance abuse, mental health diagnoses (e.g., depression, anxiety and somatization), sleep patterns, work relationships, and attitudes about the medical system. Psychosocial assessments should be performed during the first physician visit or by six weeks in patients who are not making expected progress (DOWC LBP MTG, pg. 32).

// The rationale for anticipating Maximum Medical Improvement (MMI) in three more weeks is unclear. What is the evidence that the patient’s persistent subjective pain and normal exams will be any different in exactly three weeks, especially when nothing new is being tried?

Medical record documentation similar to the examples above is common in our workers’ compensation system, highlighting a significant opportunity to utilize physical therapy more thoughtfully. Both ATPs and physical therapists should quantify specific aspects of functional ability at the baseline exam and periodically over time in order to objectively gauge progress (see Figure 1 for examples of acceptable functional status documentation). ATPs should carefully and regularly review the physical therapist’s notes and assume primary responsibility for deciding how much PT is warranted based on whether functional gains are being realized by the ends of “time-to-produce-effect” intervals. If there is inadequate evidence of functional gain, PT should be discontinued. Both physical therapists and ATPs should avoid placing excessive emphasis on pain relief. Without undue delay, psychosocial factors should be assessed and used to inform treatment plans. Finally, it is wise to avoid “cutting-and-pasting” elements and careless use of templates in the electronic health record. If these caveats are followed, the quality of care for our injured workers will be significantly enhanced.

What did you think of this exercise? Would you like us to create more like it? I’d love to hear from you at tom.denberg@pinnacol.com.

Figure 1: Examples of quantifiable functional status documentation in physical therapy*

  1. Lumbar Active Range of Motion (AROM)
    Flexion – Hand to feet (Within normal limits)
    Extension – Within normal limits
    Right rotation – Within normal limits
    Left rotation – 75% of normal
    Right flexion – Within normal limits
    Left flexion – 40% of normal
  2. Owestry Disability
    Assessment: Initial           Percentage: 30%
  3. Roland-Morris Back Pain Questionnaire
    Assessment: Visit #6
    Score: 28% (33% improvement from baseline)
  4. Physical Performance
    Lift 25 lb box from floor to/from waist – able to perform with mild guarding and mild pain
    Push 50 lb cart for 10 feet – able to perform over 6 feet with moderate pain

*These examples are not exhaustive. Therapists may evaluate and follow one or more measures at a time. Functional gain is demonstrated when there is clinically meaningful improvement over a “time-to-produce-effect” interval. The persistence of pain and changes in pain uncorrelated with physical findings do not support continuation of physical therapy beyond a “time-to-produce-effect” interval.

References

State of Colorado Department of Labor and Employment, Division of Workers’ Compensation, Medical Treatment Guideline, Chronic Pain Disorder, Effective Nov. 30, 2017.

State of Colorado Department of Labor and Employment, Division of Workers’ Compensation, Medical Treatment Guidelines, Low Back Pain, Effective March 30, 2014.

University of Michigan, Michigan Medicine Quality Department, Guidelines for Clinical Care: Acute Low Back Pain, Effective Jan. 2010.

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