Low Back Pain
Conditions
Keywords
low back pain, physical therapy, emergency department, functioning, disability, opioid
Brief summary
Emergency department (ED)-initiated physical therapy is a rapidly growing resource and represents a promising treatment approach to low back pain. This clinical trial will evaluate an innovative model of an emergency department embedded physical therapist to treat patients with acute low back pain, with a focus on improving patient functioning and reducing opioid use.
Detailed description
Low back pain represents a significant health care burden in the United States and accounts for nearly four million emergency department (ED) visits per year. In nearly two thirds of these visits, an opioid medication is administered or prescribed, making low back pain the most common reason for which opioids are prescribed. Despite this aggressive medication-based approach, patient outcomes after an ED visit for back pain remain poor: after three months, nearly half of all patients report persistent functional impairment, and one in five patients report continued opioid use. ED-initiated physical therapy (ED-PT) is a promising new resource to improve patient care for low back pain. A growing number of EDs now have dedicated physical therapists that evaluate and treat patients through a combination of education, prognostic guidance, and early mobilization and exercise. Preliminary data indicate that patients receiving ED-PT, compared to usual care, report more rapid functional improvement and use fewer opioids. However, these observational data are limited by biases in treatment selection due to physician discretion in which patients receive ED-PT, as well as other measured and unmeasured confounders. To more rigorously evaluate the efficacy of ED-PT for acute low back pain, the investigators will conduct a single-center physician-randomized trial of an embedded physical therapy intervention (NEED-PT) versus usual care in ED patients with acute low back pain, comparing a primary outcome of pain-related functioning and a secondary outcome of opioid use at the primary endpoint of three months.
Interventions
OTHERED Physical Therapy
All ED Physical Therapy treatment classifications involve a combination of exercise, range of motion, education, prognostic guidance, and reassurance. Patients are provided with an individualized home exercise plan based on their matched treatment classification and/or active rest.
OTHERUsual Care
Includes any diagnostic imaging, patient education and reassurance, and administration or prescribing of analgesic medications, as per the treating physician's usual and customary practice.
Sponsors
Agency for Healthcare Research and Quality (AHRQ)
Northwestern University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age ≥ 18 years * Low back pain (originating between 12th rib and buttocks) * Symptom duration ≤ 30 days (current episode) * Evaluated by a physician randomized to either study arm * Evaluated when ED physical therapy is available (e.g., Mon-Fri, 8am-4pm) * Likely to be discharged home (based on physician assessment) * Ability to complete follow-up data collection electronically or by telephone * English-speaking
Exclusion criteria
* Chronic low back pain or prior lumbar surgery * Serious red-flag signs/symptoms (bladder/bowel incontinence, saddle anesthesia, debilitating motor weakness) * Obvious non-musculoskeletal etiology for low back pain (e.g., shingles, kidney stone) * Other concomitant injuries or pain (e.g., closed head injury, shoulder pain) * Unable to ambulate at baseline * Known pregnancy, under police custody, unable to consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| PROMIS Pain Interference (PROMIS-PI) | Three months after the index ED visit. | PROMIS-PI measures the self-reported consequences of pain on relevant aspects of a person's life, including social, cognitive, emotional, physical, and recreational activities. We will use the computer-adaptive format to minimize respondent burden. Scores are standardized to the general U.S. population, with a score of 50 representing the population mean. The time frame of interest for the PROMIS-PI is in the past 7 days, meaning that participants provide responses based on their symptoms over the last week. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Modified Oswestry Disability Index (ODI) | Three months after the index ED visit. | The ODI contains 10 questions relating to low back pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, and employment/homemaking. The ODI score ranges from zero (no disability) to 100 (maximum disability). The time frame of interest for the ODI is today, meaning that participants provide responses based on their current symptoms on the day of survey response. The modified ODI replaces an item from the original ODI pertaining to sex life with a new item pertaining to employment/homemaking. |
| Patient-Reported Opioid Use in Last 24 Hours | Three months after the index ED visit. | Patient-reported opioid use will be collected using a customized instrument assessing whether participants have taken any opioid medication in the last 24 hours (binary yes/no). The 24-hour timeframe was selected to maximize accuracy in patient recall and has been used previously. In brief, opioid medications are listed by brand and generic names; a yes response to any medication triggers an additional query asking the participant to specify the medication dose (e.g., oxycodone 10mg) and quantity (e.g., four pills), allowing for standardization by morphine milligram equivalents. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Numeric Pain Rating Scale (NPRS) | Three months after the index ED visit. | The NPRS measures pain intensity from 0 to 10 and is easily understood by laypersons, clinicians, and researchers. We will assess a single item relating to average pain intensity over the last 24 hours. |
| Global Rating of Change (GROC) | Three months after the index ED visit. | The GROC is a single-item survey used to evaluate overall recovery from low back pain from the time that you began having pain until now. Responses are provided on a 15-point Likert scale ranging from a very great deal worse to a very great deal better. |
| Pain Catastrophizing Scale (PCS-4) | Three months after the index ED visit. | The original PCS is a 13-item survey measuring the degree to which an individual catastrophizes in response to pain. PCS scores correlate closely with pain intensity and disability over time; higher PCS scores are associated with progression from acute to chronic pain. We will utilize the brief 4-item PCS measure containing original items 3, 6, 8, and 11. |
| Opioid Prescription Filling | Three months after the index ED visit. | Opioid prescription filling data will be queried in the state prescription monitoring database. |
| Advanced Healthcare Resource Utilization | Three months after the index ED visit. | We will assess the proportion of participants who utilized any advanced healthcare resources for low back pain after their index ED visit, defined as advanced imaging (e.g., magnetic resonance imaging) or procedures/surgery (e.g., epidural steroid injection, lumbar discectomy). |
| ED Diagnostic Imaging Utilization | Index ED 1 day visit. | We will assess the proportion of ED visits in which any diagnostic imaging of the lower back was performed, including plain radiography, computed tomography, or magnetic resonance imaging. |
| Pain Self-Efficacy Questionnaire (PSEQ-4) | Three months after the index ED visit. | The original PSEQ is a 10-item survey measuring the confidence with which individuals can do things despite pain. We will utilize the brief 4-item PSEQ measure containing original items 4, 6, 8, and 9. |
| Patient-Reported Prescription Analgesic Use in Last 24 Hours | Three months after the index ED visit. | Patient-reported prescription analgesic use will be collected using the same customized instrument described above for opioid use. Prescription analgesics include the following: opioids, benzodiazepines, skeletal muscle relaxants, and gabapentinoids. |
| Prescription Analgesic Filling | Three months after the index ED visit. | Prescription analgesic filling data will be queried in the state prescription drug monitoring database. Prescription analgesics include opioids, benzodiazepines, skeletal muscle relaxants, and gabapentinoids. |
Countries
United States
Outcome results
None listed