Early Referral of Patients With Recent-Onset Sciatica to Physical Therapy Improves Clinical Outcomes

Compared with usual care, referring patients with recent-onset sciatica to physical therapy had better clinical outcomes. These results, from a randomized clinical trial, were published in the Annals of Internal Medicine.

Participants (n=220) were recruited at the University of Utah and Intermountain Healthcare between 2015 and 2018 to participate in this single-blind, parallel-group, randomized trial (ClinicalTrials.gov Identifier: NCT02391350). They had not been treated for sciatica in the 6 months prior to recruitment. All participants had an Oswestry Disability Index (OSW) score of 20 or more and had been experiencing symptoms consistent with sciatica for 90 days or less. Participants were randomly assigned in a 1:1 ratio to receive either early physical therapy or usual care. Patient symptoms were reassessed at 6 and 12 months.

All participants received imaging and medication prior to study enrollment, and all participants were given a copy of The Back Book, a patient education booklet with evidence-based messaging. Those in the usual care group (n=110), received no further interventions. Early physical therapy (n=110) included both exercise and manual therapy at each session. Participants were instructed to do exercises every 4 to 5 hours on days without a physical therapy session. They attended 2 sessions per week for 2 weeks, followed by 1 to 2 weekly sessions for 2 additional weeks.

Participants were aged mean 39 years (±11.2 years), 48.6% were women, and the mean duration of symptoms was 35.8 days (±26.1 days). The average OSW score was 35.8 (±15.8) and 38.9 (±13.8) points for those assigned to the usual care and early physical therapy cohorts, respectively.

The majority of participants in the early physical therapy cohort (90.1%) attended an average of 5.5 (±2.4) sessions during which they were given exercise therapy (96.4%), manual therapy (67.6%), and traction (13.6%). Many participants in the early physical therapy cohort (37%) reported side effects, most commonly back pain or stiffness.

At 6 months, the participants in the early physical therapy group had a greater improvement in OSW scores (relative difference, -5.4; 95% CI, -9.4 to -1.3; P =.009). This OSW score group difference was maintained through 1 year (relative difference, -4.8; 95% CI, -8.9 to -0.7). Similar differences for back pain intensity were reported between the treatment groups at 6 months (relative difference, -0.7; 95% CI, -1.3 to -0.2) and 1 year (relative difference, -1.0; 95% CI, -1.6 to -0.4).

At 1 year, rates of surgery (6.4% vs 8.3%), lumbar epidural injection (12.8% vs 13.9%), advanced imaging scans (28.4% vs 22.2%), and emergency visits (10.1% vs 9.3%) were similar between usual care and early physical therapy groups, respectively.

Study limitations include imbalanced clinician contact between treatment groups, as well as the use of multimodal physical therapy, which may have introduced bias.

“Our results found that [early physical therapy] referral after an initial primary care visit for recent-onset [low back pain] and sciatica resulted in greater improvement in disability and secondary outcomes than [usual care] across the 1-year follow-up,” the researchers concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Fritz JM, Lane E, McFadden M, et al. Physical therapy referral from primary care for acute back pain with sciatica: a randomized controlled trial. Published online October 5, 2020. Ann Intern Med. doi: 10.7326/M20-4187