Sciatica: early PT helps longterm

 A recent study found that early physical therapy for patients with acute back pain with sciatica lead to some improved short-term and long-term outcomes. Study funded by the Agency for Healthcare Research and Quality 

 

Details: 

-- 220 adults in 2 health systems in Utah who had recent sciatica were randomized to usual care with one session of education vs early physical therapy with one education session, then referral for 4 weeks of physical therapy 

-- eligibility: age 18 to 60yo, Oswestry Disability Index (OSW) score of 20 or more, current symptoms for <90 days, symptoms extending below the knee in the past 72 hours, and examination consistent with sciatica with positive straight leg raising or consistent sensory or motor deficit 

    -- OSW is a 10-item measure of low back pain (LBP)-related disability, with scores of 0-100 (high score=more disability)

    -- minimum clinically important difference is considered to be 6-8 points for acute LBP and sciatica 

-- mean age 39, 49% women, 82% white, 14% Latinx, BMI 30, 50% completed post-high school degree, 78% employed, 10% current smoker

-- 4% diabetes, 9% hypertension, 21% anxiety, 21% depression, 20% upper back/neck pain 

-- meds: NSAIDs 63%, opioids 22%, muscle relaxants 23%, oral steroids 13%, gabapentin 7% 

-- x-ray 40%, advanced imaging 18%,mean OSW 37 

-- mean duration of current symptoms: 36 days 

--OSW 37, mean numeric pain rating scale score ( 0-10, higher score=more pain) for back pain intensity 5, for leg pain intensity 4, mean Fear-Avoidance Beliefs Questionnaire score (0-24 for physical activity, higher score=more fear avoidance beliefs) 6, mean EuroQual 5-dimension tool (self-rated overall health from 0-100 with lower=worse) 20 

-- all patients were referred after an initial primary care visit, in which all received medication and imaging referrals at the discretion of the primary care provider 

-- all patients got a copy of The Back Book, a patient education booklet with evidence-based message about favorable low back pain prognosis, and the importance of remaining active and avoiding bedrest 

-- usual care (UC): no further interventions after receiving this booklet 

--early physical therapy (EPT): scheduled to begin physical therapy within 3 days, with emphasis on exercise and manual therapy intended to centralize the pain (i.e. use of movements or positions that move symptoms toward the spinal midline, typically with lumbar extension exercises) and to diminish sciatica symptoms. Other modalities such as traction were used in some, at discretion of physical therapists. The EPT protocol was 6-8 physical therapy sessions over 4 weeks, 2 per week for the 1^st 2 weeks and 1 to 2 per week for the next 2 weeks. Participants were provided with written directions to do assigned exercises every 4-5 hours on days between sessions. 

-- primary outcome was Oswestry Disability Index (OSW) at 6 months 

-- secondary outcomes were pain intensity, patient-reported treatment success, healthcare use, and missed workdays 

-- approximate 90% completed the various assessments at 4 weeks, 6 months, and one year; 90% in the EPT group began treatment, receiving a mean of 5.5 PT sessions 

 

Results: 

-- primary outcome of OSW at 6 months:  

    --early physical therapy (EPT) group vs usual care (UC) group: relative difference -5.4 points (-9.4 to -1.3), p=0.009 

-- at 4 weeks (all results below comparing EPT vs UC): 

    --OSW: -17.0 vs -8.8, difference -8.2 (-12.1 to -4.3) 

    -- numeric pain rating scale/back pain: -2.4 vs -1.0, difference -1.4 (-2.0 to -0.9) 

    -- numeric pain rating scale/leg pain: -1.8 vs -1.0, difference -0.8 (-1.4 to 0.2) 

    -- Fear-Avoidance Beliefs Questionnaire: -4.9 vs -3.2, difference -1.8 (-3.5 to -0.1) 

    -- EQ-5D/quality of life: 0.12 vs 0.05, difference 0.07 (0.02 to 0.11) 

-- at 6 months: 

    --OSW: -22.4 vs -17.0, difference -5.4 (-9.4 to -1.3), p=0.009 

    -- numeric pain rating scale/back pain: -2.3 vs -1.5, difference is -0.7 (-1.3 to -0.2) 

    -- numeric pain rating scale/leg pain: -1.8 vs -1.9, difference 0.1 (-0.5 to 0.8) 

    -- Fear-Avoidance Beliefs Questionnaire: -5.6 vs -4.9, difference -0.7 (-2.5 to 1) 

    -- EQ-5D/quality of life: 0.15 vs 0.14, difference 0.02 (-0.03 to 0.07) 

-- at one year: 

    --OSW: -22.5 vs -17.7, difference -4.8 (-8.9 to -0.7) 

    -- numeric pain rating scale/back pain: -2.6 vs -1.6, difference -1.0 (-1.6 to -0.4) 

    -- numeric pain rating scale/leg pain: -2.2 vs -1.8, difference -0.4 (-1.1 to 0.2)  

    -- Fear-Avoidance Beliefs Questionnaire: -7.3 vs -3.7, difference -3.6 (-5.4 to -1.8) 

    -- EQ-5D/quality of life: 0.17 vs 0.13, difference 0.04 (-0.01 to 0.09) 

-- 37% of those receiving EPT reported a total of 133 side effects, most were increased back pain and stiffness; 13 side effects were rated by the patient as severe with respect to intensity, and 7 of these persisted beyond 24 hours 

-- over the one-year period: 7.4% ultimately had surgery, 13% injections, 25% advanced imaging, 10% had ED visits for back pain or sciatica 

-- patient self-reported treatment success: at 4 weeks 29% in EPT group vs 12% UC, and at one year 45% vs 28% 

-- missed workdays: no difference between the groups, though for those who missed work, it was 0.7 days per month for EPT and 1.2 days per month for UC 

 

Commentary:  

-- back pain is a 2^nd most common reason for primary care visit, and costliest medical condition in the US ($134 billion spent in 2016) 

-- sciatica occurs in about 30% of low back pain, annual incidence of 1 to 5% 

-- overall prognosis of low back pain with sciatica is worse than just regular axial low back pain 

    -- observationally, 45% of patients with low back pain with sciatica do not have significant improvement in disability at one year, 34% report chronic pain at 2 years

-- outcomes tend to be worse in those having leg pain from sciatica that extends distal to the knee, including increased healthcare usage and surgery at one year 

-- cornerstones of therapy have been remaining active/avoiding bedrest, and use of NSAIDs, with consideration of systemic steroids or weak opioids if NSAIDs inadequate

 

-- overall, the study above found that EPT after the primary care visit was more effective in reducing disability than UC, with greater improvement in disability and back pain intensity across all follow-up times; and patients receiving EPT were much more likely to rate their treatment is successful at 4 weeks and one year 

    -- the magnitude of improvement was greatest in the OSW disability score, though on average this was somewhat below what was felt to be the minimum clinically important difference 

-- many primary care providers use a stepped-care approach in patients who present with low back pain and sciatica, with an initial period of advice, medication, and self-management and a referral to PT for those with a much improvement 

 

Limitations of study: 

-- those receiving EPT had more contact with healthcare providers, which might have increased the placebo effect: study was not a blinded, of necessity 

-- the EPT protocol involve potentially many different PT interventions, and they were not able to isolate any individual intervention as being maximally effective 

-- the UC protocol involved education, with The Back Book pamphlet, likely more than what is actually done routinely in primary care 

-- the study population was 83% white and 86% non-Hispanic, limiting generalizability

-- and, as a study, there is a selection bias: those willing to participate are likely more motivated than the general population

so, pretty consistent improvement in most measurements in people receiving an early PT program as designed above, and the improvement was noted even at 1 year. Though the disability index on average did not reach what was considered to be the minimal clinical effectiveness threshold, it was quite close. and,  almost half the patients exceeded that limit

and, by the 4-week and 1-year marks, up to twice as many felt that the early PT treatment was a success. sounds pretty good to me.....

other blogs on low back pain:

--http://gmodestmedblogs.blogspot.com/2018/07/gabapentinoids-still-not-help-low-back.html , finding that gabapentin and pregabalin were ineffective

--http://gmodestmedblogs.blogspot.com/2018/03/opioids-not-better-for-chronic.html , finding that opioids were not effective

--http://gmodestmedblogs.blogspot.com/2017/03/acute-low-back-pain-diazepam-not-help.html , finding that diazepam was not helpful

-- http://gmodestmedblogs.blogspot.com/2016/03/low-back-pain-treatment-per-ahrq-review.html , an older review by AHRQ finding more benefit overall with nonpharmacologic interventions

--http://gmodestmedblogs.blogspot.com/2016/03/low-back-pain-improves-with-stress.html , finding improvement with stress reduction -- mindfulness and cognitive behavioral therapy

--http://gmodestmedblogs.blogspot.com/2017/06/yoga-for-chronic-low-back-pain.html , finding that yoga was as good as PT

--http://gmodestmedblogs.blogspot.com/2017/04/home-based-cbt-for-low-back-pain.html , finding that home-based CBT was as good as in-person CBT

geoff

 

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