Patient Perspectives on Seeking Emergency Care for Acute Low Back Pain and Access to Physical Therapy in the Emergency Department.

STUDY OBJECTIVE: Low back pain is a common reason for visiting the emergency department (ED), yet little is known about patient motivations for seeking emergency care. The purpose of this study was to explore patient perspectives on visiting the ED for low back pain to inform a more patient-centered approach to emergency care. METHODS: We conducted focus group discussions and individual interviews among patients visiting an urban academic ED for acute low back pain. We recruited participants from an ongoing prospective study of 101 patients receiving either ED-initiated physical therapy or usual care. We conducted discussions, and interviews using an a priori developed discussion guide. We audio recorded, transcribed, and iteratively content analyzed the data using a consensual qualitative approach until thematic saturation was reached. RESULTS: We conducted 4 focus group discussions among 18 participants (median age 46.5 years, 66.7% women, 61.1% Black) and individual interviews with 27 participants (median age 45 years, 55.6% women, 44.4% White). No new themes emerged during the fourth and final focus group. We identified 5 summary themes: (1) the decision to seek emergency care for low back pain is motivated by severe pain, resulting disability, and fears about a catastrophic diagnosis, (2) participants sought various goals from their ED visit but emphasized the primacy of pain control, (3) participants were reluctant to use pain medications but also acknowledged their benefit, (4) participants perceived a number of benefits from direct access to an ED physical therapist in the ED, and (5) participation in physical therapy ultimately facilitated recovery, but the pain was a barrier to performing exercises. CONCLUSIONS: These patient perspectives and resulting themes may be used to inform a more patient-centered emergency care experience and contextualize quantitative research findings on ED care for low back pain.

Embedded emergency department physical therapy versus usual care for acute low back pain: a protocol for the NEED-PT randomised trial.

INTRODUCTION: Low back pain is a common problem and a substantial source of morbidity and disability worldwide. Patients frequently visit the emergency department (ED) for low back pain, but many experience persistent symptoms at 3 months despite frequent receipt of opioids. Although physical therapy interventions have been demonstrated to improve patient functioning in the outpatient setting, no randomised trial has yet to evaluate physical therapy in the ED setting. METHODS AND ANALYSIS: This is a single-centre cluster-randomised trial of an embedded ED physical therapy intervention for acute low back pain. We used a covariate-constrained approach to randomise individual physicians (clusters) at an urban academic ED in Chicago, Illinois, USA, to receive, or not receive, an embedded physical therapist on their primary treatment team to evaluate all patients with low back pain. We will then enrol individual ED patients with acute low back pain and allocate them to the embedded physical therapy or usual care study arms, depending on the randomisation assignment of their treating physician. We will follow patients to a primary endpoint of 3 months and compare a primary outcome of change in PROMIS-Pain Interference score and secondary outcomes of change in modified Oswestry Disability Index score and patient-reported opioid use. Our primary approach will be a modified intention-to-treat analysis, whereby all participants who complete at least one follow-up data time point will be included in analyses, regardless of their or their physicians' adherence to their assigned study arm. ETHICS AND DISSEMINATION: This trial is funded by the US Agency for Healthcare Research and Quality (R01HS027426) and was approved by the Northwestern University Institutional Review Board. All physician and patient participants will give written informed consent to study participation. Trial results will be submitted for presentation at scientific meetings and for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT04921449).

A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain.

OBJECTIVE: Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain. METHODS: This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models. RESULTS: For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]). CONCLUSION: In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored. IMPACT: ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes. LAY SUMMARY: Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care.

OBJECTIVE: Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting. METHODS: This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression. RESULTS: 74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83). CONCLUSIONS: In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.

Physical therapy in the emergency department: A new opportunity for collaborative care.

Emergency department-initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapist's expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.

Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.

PURPOSE: Clinical observation suggests that hip abductor weakness is common in patients with low back pain (LBP). The purpose of this study is to describe and compare the prevalence of hip abductor weakness in a clinical population with chronic non-specific LBP and a matched sample without LBP. METHODS: One hundred fifty subjects with chronic non-specific LBP and a matched cohort of 75 control subjects were recruited. A standardized back and hip physical exam was performed. Specifically tensor fascia lata, gluteus medius, and gluteus maximus strength were assessed with manual muscle testing. Functional assessment of the hip abductors was performed with assessment for the presence of the Trendelenburg sign. Palpation examination of the back, gluteal and hip region was performed to try and reproduce the subject's pain complaint. Friedman's test or Cochran's Q with post hoc comparisons adjusted for multiple comparisons was used to compare differences between healthy controls and people with chronic low back pain for both the affected and unaffected sides. Mann-Whitney U was used to compare differences in prevalence between groups. Hierarchical linear regression was used to identify predictors of LBP in this sample. RESULTS: Gluteus medius is weaker in people with LBP compared to controls or the unaffected side (Friedman's test, p < 0.001). The Trendelenburg sign is more prevalent in subjects with LBP than controls (Cochran's Q, p < 0.001). There is more palpation tenderness over the gluteals, greater trochanter, and paraspinals in people with low back pain compared to controls (Cochran's Q, p < 0.001). Hierarchical linear regression, with BMI as a covariate, demonstrated that gluteus medius weakness, low back regional tenderness, and male sex were predictive of LBP in this sample. CONCLUSION: Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP. Future investigations should validate these findings with quantitative measures as well as investigate the effect of gluteus medius strengthening in people with LBP.