Earlier Physical Therapy Referral Tied to Better Sciatica Outcomes

By Lisa Rapaport

October 06, 2020

(Reuters Health) - People with recent-onset back pain with sciatica who receive four weeks of physical therapy experience less disability over the next year than those who receive only usual care, a small trial suggests.

Researchers randomly assigned 220 adults who presented to primary care for an initial consultation for sciatica of less than 90 days duration 1:1 to receive either usual care alone or in combination with four weeks of physical therapy. After one year, the intervention group assigned to early physical therapy was more likely to report treatment success (relative risk 1.6) than the group receiving only usual care.

"For primary care providers the take-home message is to offer these patients with back pain and sciatica the option of attending physical therapy, particularly as an option to replace opioid management, which has not been shown to be very beneficial for these patients, as an initial treatment strategy."

All the patients in the study received any medication and imaging referrals determined necessary by their primary care providers as well as patient education materials about the importance of remaining active and avoiding bed rest to aid recovery.

In addition, participants randomized to early physical therapy received PT designed to address lower back pain and sciatica. Interventions to centralize and diminish sciatica symptoms included lumbar extension exercises as well as manual therapy such as mobilization or high velocity thrust manipulation of the lumbar spine.

The PT protocol recommended six to eight sessions during the four-week treatment period. Patients in the early physical therapy group also received written directions and instructions to do exercises at home every four to five hours on days they didn't have PT sessions.

Researchers measured the effectiveness of the intervention using the Oswestry Disability Index (OSW), with scores ranging from 0 to 100 and higher scores indicating greater disability. An improvement of 6 to 8 points is considered clinically meaningful for acute lower back pain and sciatica, the study team notes in Annals of Internal Medicine.

Participants in both the early physical therapy group and the control group improved during the study period. However, the mean change from baseline was greater with early physical therapy at four weeks (relative difference between groups -8.2 points on OSW), six months (-5.4 points), and one year (-4.8 points).

A total of 16 participants (7.4%) had surgery, 29 patients (13.2%) had injections, 55 people (25%) had advanced imaging, and 21 (9.7%) had an emergency department visit for sciatica or back pain during the study period. There was no meaningful difference between the early physical therapy group and the control group in these outcomes.

One limitation of the study is that researchers didn't balance provider time during the four weeks of early physical therapy. It also wasn't possible to blind patients or physical therapists to each participant's treatment group assignment.

The average size of the benefit was also modest, and the study didn't offer insight into the cost-effectiveness of early physical therapy, said Nadine Foster, co-author of an editorial accompanying the study and a professor of musculoskeletal health in primary care at Keele University in the UK.

"Referring all patients with sciatica for early physical therapy is a reasonable thing to do," Keele said by email. "On average patients benefit in terms of less back pain and better function."

SOURCE: https://bit.ly/33yAni0 and https://bit.ly/36HoXKq Annals of Internal Medicine, online October 5, 2020.