SPINE Volume 33, Number 16, pp 1800 –1805
©2008, Lippincott Williams & Wilkins
Physical Therapy for Acute Low Back Pain
Associations With Subsequent Healthcare Costs
Julie M. Fritz, PhD, PT, ATC,*† Joshua A. Cleland, PhD, DPT, FAAOMPT,‡
Matthew Speckman,§ Gerard P. Brennan, PhD, PT,* and Stephen J. Hunter, MS, PT, OCS*
Study Design. Case-control.
Objective. To examine the association between adher-
ence to the evidence-based recommendation for active
physical therapy care and clinical outcomes along with
subsequent healthcare utilization and charges for 1 year
after completion of physical therapy.
Summary of Background Data. Low back pain (LBP) is
a common condition associated with high costs. Many
patients with acute LBP receive physical therapy. The type
of physical therapy care provided may impact subsequent
healthcare costs.
Methods. A retrospective review was undertaken of
patients age 18 – 60 with acute (⬍90 days) LBP receiving
physical therapy covered by 1 insurance provider. Ad-
herence to the recommendation for active care was
determined from billing records. Disability (Oswestry)
and pain (numerical pain rating) were assessed at the
beginning and completion of physical therapy. Subse-
quent healthcare utilization for LBP and charges were
recorded from insurer’s databases.
Results. Four hundred and seventy-one patients were
included (mean age 41.2 years [SD ⫽ 11.0], 54% female),
28.0% received adherent care. Patients receiving adherent
care had fewer physical therapy visits (mean difference
1.3 visits, P ⬍ 0.05) with lower charges (nontrans-
formed mean difference $167, P ⬍ 0.05), greater im-
provement in pain (mean difference 12.3%, 95% confi-
dence interval [CI]: 3.2–21.3) and disability (mean
difference 17.6%, 95% CI: 11.1–24.1). During the year
after discharge, receiving adherent care was associated
with a lower likelihood of receiving prescription medi-
cation (46.2% vs. 57.2%, P ⬍ 0.05), magnetic resonance
imaging (MRI) (8.3% vs. 15.9%, P ⬍ 0.05), or epidural
injections (5.3% vs. 12.1%, P ⬍ 0.05).
Conclusion. Adherence to the recommendation for
active care was associated with better clinical out-
comes and decreased subsequent use of prescription
medication, MRI, and injections. Improving adherence
to this recommendation may present an opportunity to
improve the cost-effectiveness of care for acute LBP.
Key words: low back pain, economic analysis, physical
therapy. Spine 2008;33:1800 –1805
From the *Rehabilitation Agency, Intermountain Healthcare, and
†Department of Physical Therapy, University of Utah, Salt Lake City,
Utah; ‡Department of Physical Therapy, Franklin Pierce College, Con-
cord, New Hampshire; and §MS SelectHealth, Salt Lake City, Utah.
Acknowledgment date: November 13, 2007. Revision date: January
14, 2008. Acceptance date: February 25, 2008.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to: Julie M. Fritz, PhD, PT,
ATC, 520 Wakara Way, Salt Lake City, UT 84108; E-mail: julie.fritz@
hsc.utah.edu
1800
The prevalence of low back pain (LBP) is at epidemic
proportions in the United States and elsewhere, affecting
60% to 80% of individuals during their lifetime.1 A sur-
vey of residents of the United States found 26% of adults
reported LBP lasting at least 1 day in the past 3 months.2
Considering the prevalence of LBP, it is not surprising
the condition imposes a significant economic burden on
affected individuals, the healthcare delivery system, and
society. Total annual direct healthcare costs in the
United States incurred by patients with LBP were esti-
mated at 90 billion dollars in 1998, 60% higher than in
individuals without LBP.3 Although costs for surgical
procedures are high, rates of surgery for patients with
LBP are low, and the majority of direct healthcare costs
are related to outpatient office-based services and pre-
scription medication.3 Recent reports suggest that the
use of physical therapy for patients with LBP is increas-
ing.4,5 Although the proportion of direct healthcare costs
for LBP attributable to physical therapy care has not
been described in detail, the addition of physical therapy
to primary care management can contribute substan-
tially to direct healthcare costs for LBP.6
Clinical practice guidelines are proposed to be an im-
portant tool for maximizing clinical outcomes and con-
trolling healthcare costs for common conditions such as
LBP.7 A few clinical practice guidelines have been devel-
oped explicitly for use by physical therapists for the man-
agement of patients with LBP.8,9 These guidelines, as
well as systematic reviews and practice guidelines devel-
oped for primary care providers, are consistent in recom-
mending an active approach to care with emphasis on
maintaining and promoting activity, while avoiding pas-
sive interventions such as bed rest or physical methods
(heat/cold, ultrasound, etc.).10 –12 We previously exam-
ined patients with acute LBP receiving physical therapy
and found that adherence to this recommendation for an
active approach was associated with better clinical out-
comes of physical therapy, with fewer visits and lower
charges for care.13 Although most individuals with an
acute episode of LBP experience rapid and pronounced
improvement, it is now understood that the natural his-
tory of LBP includes subsequent periods of exacerbation
and recurrence for most individuals.14 The healthcare
resources consumed in attempts to manage the fluctuat-
ing and recurrent nature of LBP make it one of the most
expensive medical conditions in the United States.15–17
Examining the effectiveness of interventions occurring in
a period of acute symptom aggravation should therefore
include both clinical improvement in the short term, and
reductions in recurrences and associated costs in the long

term. The purpose of this study was to examine a cohort
of individuals with acute LBP receiving physical therapy.
We examined the association between adherence to the
evidence-based recommendation for an active approach
to physical therapy and short-term clinical outcomes and
subsequent healthcare utilization and charges accumu-
lated over a 1-year period after the completion of phys-
ical therapy.
Materials and Methods
Subjects
Data were collected from the clinical outcomes and financial
databases maintained by the Rehabilitation Agency of Inter-
mountain Healthcare (IHC), a private, nonprofit, integrated
health care delivery system, and SelectHealth, a nonprofit
health insurance company that is an integrated subsidiary of
IHC. The study was approved by the Institutional Review
Board of IHC.
The study sample was identified from the clinical outcomes
database maintained by the IHC Rehabilitation Agency. Pa-
tients receiving physical therapy in Rehabilitation Agency clin-
ics complete a condition-specific disability score and 0 –10 nu-
merical pain18 rating at each visit, and the scores are entered
into the clinical outcomes database. The database also includes
the patient’s age, duration of current symptoms, and dates of
service. For patients with a chief complaint of LBP, the condi-
tion-specific disability scale is the Modified Oswestry Disability
Questionnaire (OSW).19
Patients included in this analysis were those entered into the
clinical outcomes database that had an episode of care for LBP
at 1 of 10 outpatient physical therapy clinics between January
1, 2003, and December 31, 2005. Patients receiving treatment
for LBP were identified as those for whom the OSW was en-
tered as the disability scale. An episode of care was defined as
time from the date of the initial evaluation to the last visit. If no
visits occurred for more than 45 days, the episode of care was
considered complete. Patients were included if the insurance
provider for the episode of care was SelectHealth. Further in-
clusion criteria for the analysis were; age 18 – 60 years, dura-
tion of symptoms ⬍90 days, at least 3 physical therapy visits,
duration of physical therapy at least 10 days, initial OSW score
⬎10%, and no surgery date recorded.
Adherence of Physical Therapy Care
We determined adherence to the recommendation for an active
approach during physical therapy using methods described in
detail elsewhere.13 Briefly, we divided the episode of care was
divided into phase I (first 2 weeks), and phase II (2 weeks and
beyond). Adherence was determined by examining the current
procedural terminology codes billed for visits within each
phase. Codes were categorized as active (exercise and therapeu-
tic activities consistent with guideline recommendation), pas-
sive (heat/cold methods, electrical stimulation, ultrasound, etc.
that are inconsistent with recommendations), or allowed (eval-
uation, equipment, etc. unrelated to recommendations). The
ratio of active:passive codes had to be at least 3:1 for each
phase, and every visit had to have at least 1 active code for the
patient’s care to be considered adherent to guideline recom-
mendations.
Physical Therapist Training
A clinical practice guideline for primary care management of
patients with LBP was developed at IHC in 2004. Consistent
Physical Therapy for Acute LBP • Fritz et al 1801
with other practice guidelines, this guideline advocated an ac-
tive approach to management. The guideline was disseminated
to physical therapists working at IHC, but no explicit training
was received, and therapists were not trained in the criteria for
adherence used in this analysis.
Short-term Clinical Outcomes of Physical Therapy
During the episode of physical therapy care, clinical outcomes
were assessed using the OSW and pain rating. The OSW mea-
sures disability related to LBP and has high levels of test-retest
reliability and responsiveness to change in patients with LBP.19
The numerical pain rating asks patients to rate their pain from
0 (no pain) to 10 (worst imaginable pain).20 Pain rating scales
have been shown to have concurrent and predictive validity as
measures of pain intensity and responsiveness to change for
patients with LBP.18 Pain rating and OSW scores were ex-
tracted from the database for the initial and final physical ther-
apy visit for each patient. Change scores were calculated by
subtracting the final score from the initial score. Percentage
change was calculated as ((initial score-final score)/final score *
100%).
Subsequent Health Care Utilization and Charges
Records from the clinical outcomes database of included pa-
tients were linked to financial databases using the enterprise
master patient index number. Charges for the episode of phys-
ical therapy care were recorded. Additional charges billed to
the patient’s insurance related to the management of LBP were
collected for a 1-year period from the conclusion of the episode
of physical therapy care. We identified charges related to LBP
as those that were associated with 1 of the following Interna-
tional Classification of Diseases codes: 719.45, 719.55, 721.3,
722.1, 722.2, 722.52–722.93, 724.0, 724.02, 724.2, 724.3–
724.9, 737.3, 739.4, 756.11, 756.12, 846.0 – 846.3, 846.8,
846.9, 847.2, 847.3. Charges represented standard billed
charges and were collected for prescription medication, office
or emergency room visits, inpatient/surgical services, and diag-
nostic procedures. Charges from 2003–2005 were adjusted by
4% annually to reflect inflation of medical costs.
Data Analysis
Baseline characteristics at the beginning of the physical therapy
episode of care were compared between patients receiving
guideline-adherent versus nonadherent care using indepen-
dent-group t tests or appropriate nonparametric alternatives.
We also compared the number of visits and duration of the
physical therapy episode of care using nonparametric Mann-
Whitney U tests because of the skewed distribution of these
variables. An ␣-level of P ⬍ 0.05 was used for all comparisons.
We used linear mixed model analyses to examine the rela-
tionship between guideline adherence and clinical outcomes of
the physical therapy episode of care controlling for symptom
duration, age, sex, year of admission, and baseline pain and
disability. The mixed model was used to account for the poten-
tial correlation among patients nested within physical therapy
clinics. Separate analyses were performed using percentage
change in pain and disability as dependent variables. We also
compared the proportion of patients achieving a successful outcome
in each group using a Pearson ␹2 test. Consistent with previous
studies,21,22 a successful outcome was defined as achieving at
least 50% improvement on the OSW-disability score. Charges
for the physical therapy episode of care between groups were
compared using linear mixed model with the covariates de-
1802 Spine • Volume 33 • Number 16 • 2008
Table 1. Descriptive Characteristics of Study Subjects
All Subjects (n ⫽ 471)
Age 41.2 (11.0)
Sex (% female) 53.9
Symptom duration (d) 31.0 (25.0) median ⫽ 24
Initial Oswestry score 39.4 (14.6)
Initial pain rating 5.5 (2.3)
*Mann-Whitney U test.
†P ⬍ 0.05 for comparison of adherent and nonadherent groups.
scribed above. Charge data underwent square root transforma-
tion before analysis to reduce positive skewness.
Evaluation of the association between receiving adherent
care in physical therapy and subsequent healthcare utilization
began with ␹2 comparisons of utilization rates. We compared
the proportion of patients in each group who received prescrip-
tion medication (nonsteroidal anti-inflammatories, opioid an-
algesics, skeletal muscle relaxants, or corticosteroids), addi-
tional physician visits (e.g., family practice physical medicine,
orthopedic surgery, etc.), visits to an emergency room or urgent
care facility, diagnostic imaging procedures (e.g., radiographs,
magnetic resonance imaging [MRI], etc.), additional rehabili-
tation visits (physical therapy or chiropractic), injection, or
surgical procedures for the management of LBP in the 1-year
period after completion of the physical therapy episode of care.
When significant univariate associations were identified, we
also constructed multivariate logistic regression models to
examine the association between adherent physical therapy
care and subsequent healthcare utilization adjusting for age,
sex, and duration of symptoms. Adjusted odds ratios (OR)
with 95% confidence intervals (CI) were computed. We com-
pared mean charges for subsequent healthcare utilization be-
tween groups using linear mixed model procedures with the
data transformation and covariates described previously. We
examined the association between incurring high charges and
adherent physical therapy care. Patients with high charges were
defined as those in the 75th percentile of the distribution of
adjusted subsequent healthcare charges. Adjusted OR values
were calculated as previously described.
Results
During the time period of the study, 471 patients with
LBP met the criteria for inclusion. Descriptive data for
these patients is contained in Table 1. Using the defini-
tion for adherence to the recommendation for an active
approach described previously, 132 patients (28.0%) re-
ceived adherent care and 339 (72.0%) received nonad-
Table 2. Clinical and Financial Outcomes From the Episode of Care in Physical Therapy
All Subjects (n ⫽ 471)
No. physical therapy visits 5.5 (2.5)
Duration of physical therapy care (d) 28.5 (19.5) median ⫽ 22
Physical therapy charges $683 (334)
Percent change in Oswestry 42.0% (34.0)
Percent change in pain rating 41.9% (46.7)
Successful outcome of physical therapy (n %) 43.7%
Numbers represent mean (standard deviation) unless otherwise indicated.
*Mann-Whitney U test.
†P ⬍ 0.05 for comparison of adherent and nonadherent groups.
Adherent (n ⫽ 132) Nonadherent (n ⫽ 339)
40.3 (11.0) 41.5 (11.0)
53.0 54.3
33.9 (24.4)*† median ⫽ 30 30.0 (25.2)*† median ⫽ 21
36.1 (13.3)† 40.7 (15.0)†
4.7 (2.3)† 5.8 (2.2)†
herent care. Patients receiving adherent care experienced
greater improvement in disability (mean difference in
percentage change on the Oswestry score ⫽ 16.2%, 95%
CI: 9.5–22.9), and pain intensity (mean difference in per-
centage change on the pain rating ⫽ 11.3%, 95% CI:
1.6 –20.9), and were more likely to experience a success-
ful physical therapy outcome (59.1% vs. 37.8%, P ⬍
0.05) than patients receiving nonadherent care (Table 2).
Patients receiving adherent care also attended fewer
physical therapy visits, had a shorter length of stay, and
lower charges for physical therapy care (Table 2).
Overall, 296 patients (62.8%) had billed charges for
additional healthcare related to the management of LBP
in the 1-year period after completion of the physical ther-
apy episode of care. Among patients receiving adherent
care in physical therapy, the rate of additional healthcare
utilization was 55.3% compared with 65.8% among pa-
tients receiving nonadherent physical therapy (P ⬍ 0.05).
Associations between adherent care in physical therapy
and subsequent utilization of specific types of care are
provided in Table 3. Receiving adherent care was asso-
ciated with a decreased use of prescription medication
(adjusted OR ⫽ 0.64, 95% CI: 0.43– 0.97, P ⬍ 0.05).
Among the most common prescription medications, re-
ceiving adherent care was particularly associated with a
decreased use of muscle relaxants (adjusted OR ⫽ 0.59,
95% CI: 0.35– 0.99, P ⬍ 0.05). Adherent care was also
associated with a decreased likelihood of receiving diag-
nostic imaging procedures (adjusted OR ⫽ 0.53, 95%
CI: 0.31– 0.92, P ⬍ 0.05). In particular, adherent care
was associated with decreased use of MRI (adjusted
OR ⫽ 0.47, 95% CI: 0.24 – 0.94, P ⬍ 0.05). The use of
injection procedures was also less likely among patients
receiving adherent care (adjusted OR ⫽ 0.40, 95% CI:
Adherent (n ⫽ 132) Nonadherent (n ⫽ 339)
4.6 (2.0)*† 5.9 (2.2)*†
25.4 (16.2)*† median ⫽ 19 29.7 (20.6)*† median ⫽ 22
$562 (269)† $729 (345)†
53.7% (33.1)† 37.5% (33.3)†
49.1% (45.9)† 39.2% (46.8)†
59.1%† 37.8%†
 Physical Therapy for Acute LBP • Fritz et al 1803

Table 3. Utilization of Additional Healthcare Services in the Year After the Episode of Physical Therapy Care
All Subjects (n ⫽ 471) Adherent (n ⫽ 132) Nonadherent (n ⫽ 339) Adjusted OR (95% CI)

Prescription medication 54.1 46.2* 57.2* 0.64 (0.43, 0.97)

Opioid analgesics 35.9 30.3 38.1
Nonsteroidal anti-inflammatories 35.5 32.6 36.6
Skeletal muscle relaxants 22.9 16.7* 25.4* 0.59 (0.35, 0.99)
Systemic corticosteroids 11.0 9.1 11.8
Physician office visits 24.0 19.5 25.7
Physical medicine 19.1 15.9 20.4
Family practice 12.7 9.1 14.2
Orthopedic surgery 7.4 6.8 7.7
Internal medicine 4.0 3.8 4.1
Neurosurgery 3.0 1.5 3.5
Emergency/urgent care visits 2.8 1.5 3.2
Diagnostic procedures 21.0 14.4* 23.6* 0.53 (0.31, 0.92)
MRI 13.8 8.3* 15.9* 0.47 (0.24, 0.94)
Spine radiographs 9.8 6.8 10.9
Nerve conduction/EMG 1.7 2.5 1.3
Computed tomography scan 1.4 0 2.1
Surgical procedures 3.2 3.8 3.0
Surgical procedure without fusion 2.3 2.3 2.4
(discectomy, etc.)
Surgical procedure with fusion 0.8 1.5 0.6
Injection procedures 13.2 9.1* 15.9* 0.40 (0.18, 0.85)
Epidural injection with fluoroscopy 10.2 5.3* 12.1* 0.40 (0.18, 0.94)
Injection without fluoroscopy 4.2 3.0 4.7
(intramuscular, trigger point, etc.)
Rehabilitation visits 9.3 9.1 9.4
Additional physical therapy 8.3 9.1 8.0
Chiropractic 1.1 0 1.5
All values are indicated in percentages, unless otherwise indicated.
OR adjusted for age, sex, and duration of symptoms are provided for services differing significantly between groups.
*P ⬍ 0.05 for comparison of adherent and nonadherent groups.

0.18 – 0.85, P ⬍ 0.05), in particular the use of fluoro-
scopically-guided procedures (adjusted OR ⫽ 0.40, 95%
CI: 0.18 – 0.94, P ⬍ 0.05).
Differences in mean charges for subsequent healthcare
costs between patients receiving adherent or nonadher-
ent care in physical therapy did not reach statistical sig-
nificance. Mean charges were $1692 (SD ⫽ $7683) for
patients receiving adherent care, and $2829 (SD ⫽
$21,728) for patients receiving nonadherent care (P ⬎
0.05). Receiving adherent physical therapy care was as-
sociated with a reduced likelihood of incurring high
charges for subsequent healthcare (adjusted OR ⫽ 0.51,
95% CI: 0.31– 0.87). Mean overall charges for care
(charges for physical therapy ⫹ charges for subsequent
healthcare) were $2255 (SD ⫽ $7665) for patients re-
ceiving adherent care and $3559 (SD ⫽ $21,720) for
patients receiving nonadherent care (P ⬎ 0.05). Receiv-
ing adherent physical therapy care was associated with a
reduced likelihood of incurring high overall charges (ad-
justed OR ⫽ 0.44, 95% CI: 0.26 – 0.75).
Discussion
Recognition of the substantial economic burden of LBP
has increased scrutiny on how healthcare resources are
used for the condition. Wide variations in clinical care
have been documented in rates of surgery, prescribing of
medications, use of imaging, and specialist referrals for
patients with LBP.23–28 Many patients experiencing an
acute exacerbation of LBP are referred to physical ther-
apy,4,5 Similar to other healthcare providers, it appears
that physical therapy care for patients with LBP is char-
acterized by widespread and unwarranted variations in
practice.29 –31 Practice variation is believed to contribute
to increased costs and suboptimal clinical outcomes.
Consistent adherence to evidence-based guidelines is ad-
vocated as an important and necessary step for improv-
ing the cost-effectiveness of care for individuals with
LBP.32,33 Our previous work found an association be-
tween improved short-term clinical outcomes and phys-
ical therapy care that was adherent to the recommenda-
tion for an active approach.13 This study extends the
previous findings by examining the association of adher-
ence to this evidence-based recommendation with
healthcare utilization in the longer term.
This study used a retrospective case-control design to
examine the association between the management pro-
vided in physical therapy and short-term clinical im-
provement and longer term reductions in the utilization
of, and charges for additional healthcare services. Al-
though this design is unable to provide causal evidence,
the results found significant associations between the
physical therapy care received during the acute phase
and greater short-term clinical improvements and reduc-
tions in subsequent use of various healthcare resources.
Patients whose physical therapy care was adherent to the
evidence-based recommendation to focus on active inter-
ventions instead of passive methods were less likely to
receive prescription medication, diagnostic, or injection
1804 Spine • Volume 33 • Number 16 • 2008
procedures in the 1-year period after the physical therapy
episode of care than those patients whose care was non-
adherent to this recommendation. Although alternative
explanations should be considered, these results suggest
an opportunity for more cost-effective care if an active
approach in physical therapy was used on a more con-
sistent basis.
The recommendation for an active approach to care
for patients with acute LBP has been supported by sev-
eral randomized clinical trials and is included in almost
all clinical practice guidelines for physicians or physical
therapists.9,10,34,35 Given these consistent recommenda-
tions, it may be surprising that adherence to an active
approach has been reported to be low in studies of both
primary care physicians and physical therapists.13,32,36
Lack of adherence to evidence-based recommendations,
however, has proven a challenge for clinicians and
healthcare systems in nearly every clinical condition that
has been studied.37 Research on methods to improve
adherence has yet to identify consistently effective strat-
egies for changing the behavior of clinicians.37 Given the
cost implications, many health plans are moving towards
greater alignment of reimbursement with provision of
care that adheres to evidence-based guidelines.38 Evi-
dence on the impact of pay-for-performance programs
on clinician behavior and clinical outcomes is beginning
to emerge, but the effectiveness of these programs is cur-
rently uncertain.39,40
The ability to effectively alter the natural history of
LBP during the acute phase has not be effectively dem-
onstrated, and therefore most primary care practice
guidelines and expert recommendations suggest a period
of “watchful waiting” without referral during the initial
weeks of an acute episode of LBP.41 We were not able to
examine a group of patients with acute LBP who did not
receive any physical therapy. Therefore, we cannot ad-
dress the cost-effectiveness of a watchful waiting ap-
proach instead of referral to physical therapy during the
initial weeks of symptoms. The results of this study,
however, suggest the potential financial impact of the
management strategies used during the acute phase of an
LBP episode.
There are several important limitations that must be
considered when interpreting the results of this study. A
case-control design does not permit conclusions regard-
ing the cause of the clinical improvement and reduced
healthcare utilization among patients receiving adherent
care in physical therapy. This association could reflect a
tendency for patients with better prognoses due to fac-
tors intrinsic to the patient (e.g., less fear of movement or
pain catastrophizing) to receive more active interven-
tions in physical therapy. We did not record these factors
at the initiation of physical therapy, and therefore we
cannot adjust for these and other potentially important
variables. We examined only direct costs related to
healthcare expenditures that were charged to the pa-
tient’s insurance. Research has demonstrated that the
majority of costs associated with LBP are indirect, re-
lated to out-of-pocket expenses and missed time at
work.42 We were unable to account for these costs in our
analysis.
Conclusion
This study found that adherence to the evidence-based
recommendation for an active approach to physical ther-
apy care for patients with acute LBP was associated with
better clinical outcomes for the episode of physical ther-
apy and decreased use of prescription medication, MRI,
and epidural steroid injections in the year after dis-
charge. Improving adherence to this recommendation in
physical therapy may have important implications for
improving outcomes and reducing subsequent health-
care costs for individuals with LBP. Further research is
needed to explore the impact of initial management
strategies on subsequent healthcare costs for patients
with acute LBP.
Key Points
● Physical therapy care provided to patients with
acute low back pain was not consistently adherent
to the evidence-based guideline recommendation
to provide active, as opposed to passive care.
● The provision of physical therapy that was ad-
herent to the guideline recommendation for active
care was associated with better clinical outcomes
for the physical therapy episode of care.
● The provision of physical therapy that was ad-
herent to the guideline recommendation for active
care was associated with lower utilization of pre-
scription medication, imaging, and injection proce-
dures.
● For patients with acute low back pain, the type of
care provided during the initial management may
have implications for subsequent health care utili-
zation and costs.
References
1. Patel AT, Ogle AA. Diagnosis and management of acute low back pain. Am
Fam Physician 2000;61:1779 –90.
2. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: esti-
mates from U.S. national surveys, 2002. Spine 2006;31:2724 –7.
3. Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health
care expenditures among individuals with back pain in the United States.
Spine 2004;29:79 – 86.
4. Feuerstein M, Marcus SC, Huang GD. National trends in nonoperative care
for nonspecific back pain. Spine J 2004;4:56 – 63.
5. Weiner DK, Kim YS, Bonino P, et al. Low back pain in older adults: are we
utilizing healthcare resources wisely? Pain Med 2006;7:143–50.
6. Kominski GF, Heslin KC, Morgenstern H, et al. Economic evaluation of four
treatments for low-back pain: results from a randomized controlled trial.
Med Care 2005;43:428 –35.
7. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered
to adults in the United States. N Engl J Med 2003;348:2635– 45.
8. Acute low back pain. Interdisciplinary Clinical Guidelines. Oslo: The Nor-
wegian Back Pain Network; 2002.
9. Bekkering GE, Hendriks HJM, Koes BW, et al. Dutch physiotherapy guide-
lines for low back pain. Physiotherapy 2003;89:82–96.
10. Koes BW, van Tulder MW, Ostelo R, et al. Clinical guidelines for the man-

agement of low back pain in primary care: an international comparison.
Spine 2001;26:2504 –13.
11. Van Tulder MW, Becker A, Bekkering T, et al. European guidelines for the
management of acute nonspecific low back pain in primary care. Eur Spine J
2006;15(suppl):S169 –S191.
12. van Tulder MW, Koes B, Malmivaara A. Outcome of non-invasive treatment
modalities on back pain: an evidence-based review. Eur Spine J 2006;15
(suppl):S64 –S81.
13. Fritz JM, Cleland JA, Brennan GP. Does adherence to clinical practice guide-
lines for patients with acute low back pain improve the quality of care
delivered by physical therapists? Med Care 2007;45:973– 80.
14. Von Korff M, Saunders K. The course of back pain in primary care. Spine
1996;21:2833–9.
15. Carey TS, Garrett JM, Jackman A, et al. Recurrence and care seeking after
acute low back pain: results of a long-term follow-up study. Med Care
1999;37:157– 64.
16. Enthoven P, Skagren E, Oberg B. Clinical course in patients seeking primary
care for back or neck pain: a prospective 5-year follow-up of outcome and
health care consumption with subgroup analysis. Spine 2004;29:2458 – 65.
17. Druss BG, Marcus SC, Olfson M, et al. The most expensive medical condi-
tions in America. Health Affairs 2002;21:105–11.
18. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale
in patients with low back pain. Spine 2005;30:1331–5.
19. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry disability ques-
tionnaire and the Quebec back pain disability scale. Phys Ther 2001;81:
776 – 88.
20. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels
needed in pain intensity measurement? Pain 1994;58:387–92.
21. Childs JD, Fritz JM, Flynn TW, et al. Validation of a clinical prediction rule
to identify patients with low back pain likely to benefit from spinal manip-
ulation. Ann Intern Med 2004;141:920 – 8.
22. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying
patients with low back pain who demonstrate short term improvement with
spinal manipulation. Spine 2002;27:2835– 43.
23. Cherkin DC, Deyo RA, Loeser JD, et al. An international comparison of
back surgery rates. Spine 1994;19:1201– 6.
24. Cherkin DC, Deyo RA, Wheeler K, et al. Physician variation in diagnostic
testing for low back pain: who you see is what you get. Arthritis Rheum
1994;37:15–22.
25. Luo X, Pietrobon R, Curtis LH, et al. Prescription of nonsteroidal anti-
inflammatory drugs and muscle relaxants for back pain in the United States.
Spine 2004;29:E531–E537.
26. Luo X, Pietrobon R, Hey L. Patterns and trends in opioid use among indi-
viduals with back pain in the United States. Spine 2004;29:884 –90.
Physical Therapy for Acute LBP • Fritz et al 1805
27. O’Neill L, Kuder J. Explaining variation in physician practice patterns
and their propensities to recommend services. Med Care Res Rev 2005;
62:339 –57.
28. Weinstein JN, Lurie JD, Olson PR, et al. United States’ trends and regional
variations in lumbar spine surgery: 1992–2003. Spine 2006;31:2707–14.
29. Jette DU, Jette AM. Professional uncertainty and treatment choices by phys-
ical therapists. Arch Phys Med Rehabil 1997;78:1346 –51.
30. Li LC, Bombardier C. Physical therapy management of low back pain: an
exploratory survey of therapist approaches. Phys Ther 2001;81:1018 –28.
31. Poitras S, Blais R, Swaine B, et al. Management of work-related low back
pain: a population-based survey of physical therapists Phys Ther 2005;85:
1168 – 81.
32. Feuerstein M, Hartzell M, Rogers HL, et al. Evidence-based practice for
acute low back pain in primary care: patient outcomes and cost of care. Pain
2006;124:140 –9.
33. González-Urzelai V, Palacio-Elua L, López-de-Munain J. Routine primary
care management of acute low back pain: adherence to clinical guidelines.
Eur Spine J 2003;12:589 –94.
34. Hagen KB, Hilde G, Jamvedt G, et al. The cochrane review of advice to stay
active as a single treatment for low back pain and sciatica. Spine 2002;27:
1736 – 41.
35. Staal JB, Hlobil H, van Tulder MW, et al. Occupational health guidelines for
the management of low back pain: an international comparison. J Occup
Environ Med 2003;60:618 –26.
36. Bekkering GE, Hendriks HJM, Van Tulder MW, et al. Effect on the process
of care of an active strategy to implement clinical guidelines on physiother-
apy for low back pain: a cluster randomized trial. Qual Saf Health Care
2005;14:107–12.
37. Grimshaw J, Eccles M, Tetroe J. Implementing clinical guidelines: current
evidence and future implications. J Cont Ed Health Prof 2004;24(suppl):
S31–S37.
38. Schaeffer LD, McMurtry DE. Variation in medical care: time for action.
Health Aff 2004;(suppl) Web Exclusives W5:117–20.
39. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of
care, and outcomes in acute myocardial infarction. JAMA 2007;297:
2373– 80.
40. Young GJ, Meterko M, Beckman H, et al. Effects of paying physicians based
on their relative performance for quality. J Gen Intern Med 2007;22:872– 6.
41. Von Korff M, Moore JC. Stepped care for back pain: activating approaches
for primary care. Ann Intern Med 2001;134:911–7.
42. Van Tulder MW, Koes B, Bouter LM. A cost-of-illness study of back pain in
the Netherlands. Pain 1995;62:233– 40.