Cited by 259Musculoskeletal pain and rehabilitationSpine and Intervertebral Disc PathologyMedical Practices and Rehabilitation

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Primary Care Referral of Patients With Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs

Fritz, Julie M., Childs, John D., Wainner, Robert S., Flynn, Timothy W.·2012·Spine

DOI 10.1097/brs.0b013e31825d32f5

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Abstract

STUDY DESIGN: A retrospective cohort. OBJECTIVE: To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs. SUMMARY OF BACKGROUND DATA: Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed. METHODS: Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined. RESULTS: Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care. CONCLUSION: Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

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Result
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Student Physical Therapists Achieve Similar Patient Outcomes as Licensed Physical Therapists: A Retrospective Comparison of Outcomes of Patients With Low Back Pain
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Physical therapists familiarity and beliefs about health services utilization and health seeking behaviour
Clewley, D. J., Rhon, D. I., Flynn, T. W., Koppenhaver, S. L., & Cook, C. E. (2018) · Brazilian Journal of Physical Therapy · doi:10.1016/j.bjpt.2018.02.002 · Cited by 3
Clinician education unlikely effective for guideline-adherent medication prescription in low back pain: systematic review and meta-analysis of RCTs
Belavy, D., Tagliaferri, S. D., Buntine, P., Saueressig, T., Sadler, K., Ko, C., Miller, C. T., & Owen, P. J. (2022) · Deakin Research Online (Deakin University) · Cited by 3
Invited Commentary
Deutscher, D., & Horn, S. D. (2014) · Physical Therapy · doi:10.2522/ptj.20140009.ic2 · Cited by 3
Predictors of treatment adherence in patients with centralized low back pain
Watson, S., Trudelle-Jackson, E. J., Weber, M. D., & Brizzolara, K. J. (2025) · Journal of Back and Musculoskeletal Rehabilitation · doi:10.1177/10538127251332211 · Cited by 2
“13,41 With the results of the current study in mind, physical therapists should take patient cost into consideration when developing their plan of care recommendations.”
Does Treating Low Back Pain With Therapeutic Exercise Reduce the Risk of Subsequent Lower Extremity Injury? A Population-Level Cohort Analysis
Foster, K., Wang-Price, S. S., Weber, M. D., Brizzolara, K. J., Yuan, X., Boeth, R., & Rhon, D. I. (2025) · Physical Therapy · doi:10.1093/ptj/pzaf122 · Cited by 2
Determining the Impact of a Physiotherapist-Led Primary Care Model for Low Back Pain: Protocol and Analysis Plan for a Cluster Randomized Controlled Trial and Embedded Process Evaluation
Miller, J., Donnelly, C. A., McClintock, C., Varette, K., Camargo, Y., Marsh, J. D., Taljaard, M., Mamun, M. S. A., Bacchus, G., Barber, D., et al. (2026) · JMIR Research Protocols · doi:10.2196/89004 · Cited by 2
“Evidence from outside of Canada suggests that early guideline-adherent PT care for LBP improves function and disability [28,29] while reducing diagnostic imaging, opioid prescriptions, and physician specialist referrals [29-31], and reducing per-person health care costs [32,33].”
Riding a Tiger: Maximizing Effects of Manual Therapies for Pelvic Pain
Bishop, M. D., Bialosky, J. E., & Alappattu, M. J. (2020) · Journal of Womenʼs Health Physical Therapy · doi:10.1097/jwh.0000000000000156 · Cited by 2
Financial impact associated with implementation of the low back pain clinical practice guideline in outpatient physical therapist practice at a large academic medical center
Kosakowski, H., Rone-Adams, S. A., Boissonnault, W. G., Harmon-Matthews, L. E., Kuczynski, J. J., Martin, M., & Briggs, M. S. (2022) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2022.2160940 · Cited by 2
“…and have found reduced PT utilization when services adhere to guideline recommendations and are initiated early, thus reducing the direct costs (Childs et al., 2015; Fritz, Childs, Wainner, and Flynn, 2012; Hanney, Masaracchio, Liu, and Kolber, 2016; Hoeijenbos et al., 2005; Liu et al., 2018).”
Background
Association between physiotherapy utilization and medical healthcare utilization and costs in adults with back pain from Ontario, Canada: a population-based cohort study
Lu, M., Wong, J. J., Côté, P., Watson, T., & Rosella, L. C. (2023) · Pain · doi:10.1097/j.pain.0000000000002957 · Cited by 2
Significant Clinical Improvement Was Predicted in a Cohort of Patients With Low Back Pain Early in the Care Process
Brennan, G. P., Snow, G. L., Minick, K. I., & Stevans, J. M. (2023) · Physical Therapy · doi:10.1093/ptj/pzad082 · Cited by 2
The care pathway of individuals with spinal disorders in a Health Care Network in the Federal District, Brazil: a retrospective study
Custódio, L. A., Marques, Y. A., de Toledo, A. M., Ferreira, A. D. S., van Tulder, M. W., da Silva, E. N., & Carregaro, R. L. (2023) · Brazilian Journal of Physical Therapy · doi:10.1016/j.bjpt.2023.100553 · Cited by 2
“37,38 This aspect is relevant because, although physical therapy has been part of the Family Health Support Centres since 2008, its operation is limited, e.g., the low population coverage due to the de ﬁ cit in the number of professionals and the great demand imposed for conditions such as low back…”
Background
Real-life implementation and evaluation of the e-referral system SIPILINK
Nun, A., Tropeano, A., Flamarion, E., Roumy, A., Azaïs, H., Dehghani, L., Auclin, É., Burgun, A., Katsahian, S., Ranque, B., et al. (2024) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2024.105605 · Cited by 2
Effectiveness and Stakeholder Views of Community-Based Allied Health on Acute Care Utilization: A Mixed Methods Review
Tian, E. J., Martin, P., Ingram, L. A., & Kumar, S. (2024) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s489640 · Cited by 2
Chronische Rückenschmerzen – medikamentöse und nichtmedikamentöse Therapieansätze
Oikonomidis, S., Lenz, M., Egenolf, P., & Eysel, P. (2025) · Die Innere Medizin · doi:10.1007/s00108-024-01843-8 · Cited by 2
“Zusätzlich gehö-ren Rückenschmerzen zu den häuﬁgsten Gründen für Arztbesuche und stellen den höchsten Prozentsatz für Überweisungen und Arbeitsbelastung für die Inanspruch-nahme von physikalischen Therapien in den USA dar [4, 5].”
Implementation Outcomes From a Pilot Study of Mindful Awareness in Body-Oriented Therapy (MABT) as a Chronic Pain Treatment Modality in an Integrative Health Clinic
Hansen, K. A., Blakeney, E. A., & Price, C. J. (2025) · Global Advances in Integrative Medicine and Health · doi:10.1177/27536130251319244 · Cited by 2
Cost of manual therapy for musculoskeletal disorders: a systematic review of systematic reviews with methodological and reporting quality
Kirker, K., Masaracchio, M. F., States, R. A., & Young, J. L. (2025) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2025.2471398 · Cited by 4
“…patient experience, improving population health, reducing costs, and improving the work life of healthcare providers) (Bachynsky, 2020; Childs et al., 2015; Fritz, Childs, Wainner, and Flynn, 2012; Fritz, Cleland, and Brennan, 2007; Hanney et al., 2016; Liu et al., 2018; Peterson et al., 2009).”
Development of a Logic Model for a Programme to Reduce the Magnetic Resonance Imaging Rate for Non-Specific Lower Back Pain in a Tertiary Care Centre
Alhowimel, A., Alodaibi, F., Alotaibi, M., Alamam, D., Alsobayel, H., & Fritz, J. M. (2021) · Healthcare · doi:10.3390/healthcare9020238 · Cited by 2
Feasibility study and process evaluation of MRI plus physiotherapy vs. physiotherapy alone in non-specific chronic low back pain among patients in Saudi Arabia
Alhowimel, A., Alotiabi, M., Coulson, N., & Radford, K. (2020) · Pilot and Feasibility Studies · doi:10.1186/s40814-020-00731-w · Cited by 3
Examination and Treatment of Lumbopelvic Spine Disorders
Olson, K. A. (2015) · Elsevier eBooks · doi:10.1016/b978-0-323-26306-1.00004-6 · Cited by 2
Effect of Patient Use of Physical Therapy After Referral for Musculoskeletal Conditions on Future Medical Utilization: A Retrospective Cohort Analysis
Sharpe, J. A., Martin, B. I., Magel, J. S., Fritz, J. M., Vanneman, M. E., & Thackeray, A. (2021) · Journal of Manipulative and Physiological Therapeutics · doi:10.1016/j.jmpt.2022.01.001 · Cited by 2
Dietary supplementation with plant extracts for amelioration of persistent myofascial discomfort in the cervical and back regions: a randomized double-blind controlled study
Pérez-Piñero, S., Muñoz-Carrillo, J. C., Echepare-Taberna, J., Luque-Rubia, A. J., Rivero, J. E. M., Muñoz-Cámara, M., Silvente, M. J. D., Valero-Merlos, E., Ávila-Gandía, V., Caturla, N., et al. (2024) · Frontiers in Nutrition · doi:10.3389/fnut.2024.1403108 · Cited by 3
Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a primary care provider. A retrospective cohort studyPreprint
Elton, D., & Zhang, M. (2022) · medRxiv · doi:10.1101/2022.06.30.22277102 · Cited by 2
Differential screen and treatment of sternocleidomastoid syndrome versus eagle syndrome: a case report
Udhawani, N. S., & Hoover, D. L. (2022) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2022.2144560 · Cited by 1
“…are widely associated with less favorable long-term outcomes, lesser patient satisfaction with the healthcare they receive, and higher healthcare utilization costs (Denninger et al., 2018; Fritz, Childs, Wainner, and Flynn, 2012; Korthals-de Bos et al, 2003; Taylor, 2020; Tsertsvadze et al., 2014).”
Background
The Association of Physiotherapy and Opioid Use With Duration of Compensated Time Loss for Workers With Low Back Pain
Low, K. K. X., Donato, M. F. D., & Gray, S. E. (2024) · Journal of Occupational and Environmental Medicine · doi:10.1097/jom.0000000000003141 · Cited by 1
Associations of Co-Occurring Chronic Conditions With Use of Rehabilitation Services in Older Adults With Back Pain: A Population-Based Cohort Study
Rundell, S. D., Karmarkar, A. M., & Patel, K. V. (2024) · Physical Therapy · doi:10.1093/ptj/pzae110 · Cited by 1
The persistence of psychological distress while waiting for pain management
Tidmarsh, L. V., Harrison, R. N., Wilkinson, H., Harrington, M. P., Ravindran, D., Norwood, S., & Finlay, K. A. (2025) · British Journal of Pain · doi:10.1177/20494637251377761 · Cited by 2
Rehabilitation versus Spine Surgery: A Narrative Review of Role of Rehabilitation in Lumbar Degenerative Spine Conditions
Rivers, W. E. (2017) · International Physical Medicine & Rehabilitation Journal · doi:10.15406/ipmrj.2017.01.00024 · Cited by 1
Key Factors Driving Physiotherapy Use in Patients with Nonspecific Low Back Pain: Retrospective Clinical Data Analysis
Alimam, D. M., Alqarni, M. J., Aljohani, M. H., Alqarni, M. A., Alsubiheen, A. M., & Alrushud, A. S. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13206261 · Cited by 1
“Higher rates can also lead to more comprehensive treatment plans [54], with therapists prescribing multiple sessions per week to achieve specific therapeutic goals more quickly [28,54–56], thereby increasing the total number of PT visits per episode of care.”
Background
Health Care Service Utilization Among People with HIV, Chronic Pain, and Depression: Utilization and Cost Outcomes from the HIV-PASS Study
Moitra, E., Stein, M. D., Busch, A. M., Pinkston, M. M., Bray, J. W., Abrantes, A. M., Baker, J. V., Weisberg, R. B., Anderson, B. J., & Uebelacker, L. A. (2024) · AIDS and Behavior · doi:10.1007/s10461-024-04554-1 · Cited by 1
“For general population patients with chronic pain, use of effective treatments, such as physical therapy, leads to significant cost savings [15, 16].”
Resistance Training in Individuals With Hip and Knee Osteoarthritis: A Clinical Commentary With Practical Applications
Masaracchio, M. F., & Kirker, K. (2022) · Strength and conditioning journal · doi:10.1519/ssc.0000000000000711 · Cited by 2
Treatment-Based Classification versus Usual Care for Management of Low Back Pain
Rhon, D. I., Fritz, J. M., Cleland, J. A., & Teyhen, D. S. (2012) · Defense Technical Information Center (DTIC) · doi:10.21236/ada575229
Acute aspecifieke lagerugpijn: perceptie, prognose en prediction rules
Hallegraeff, H. J. M. (2013) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-0287-1_5
Return to Full Duty Work: Determining the Ideal Time to Refer Occupationally Isolated Acute Low Back Pain Patients to Physical Therapy
Stephenson, A. M. (2016) · ProQuest Demo Repository
Work Injury Prevention and Management: The Role of the Physical Therapist in Injury Reduction/Prevention and Workforce Wellness
Eisenhart, M. T. (2014) · Orthopaedic Section, APTA, Inc. eBooks · doi:10.17832/isc.2014.24.1.3
Physical Therapy Utilization and Length of Stay among Patients with Low Back Pain in Florida Hospitals
Watterson, K. A. (2017) · Digital Commons - University of South Florida (University of South Florida)
Low Back Pain Prognostic Factors in the Canadian Armed Forces
Glover, S. (2014) · Library and Archives Canada (Government of Canada)

Authors: Fritz, J. M., Childs, J. D., Wainner, R. S., & Flynn, T. W.
Affiliations: Intermountain Healthcare (US)
Baylor University (US)
Texas State University (US)
Rocky Mountain University of Health Professions (US)
Corresponding author: Fritz, Julie M.
ORCID: Fritz, Julie M.
Flynn, Timothy W.
Venue: Spine
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2012-12
Volume: 37
Issue: 25
Pages: 2114-2121
ISSN: 0362-2436 (ISSN-L)
DOI: 10.1097/brs.0b013e31825d32f5
OpenAlex: W2014638499
Cited by: 259
References: 47
Citations by year: 2026: 13 · 2025: 26 · 2024: 24 · 2023: 21 · 2022: 29 · 2021: 17 · 2020: 26 · 2019: 17 · 2018: 24 · 2017: 13 · 2016: 18 · 2015: 13 · 2014: 12 · 2013: 5 · 2012: 1
FWCI: 7.23
Type: journal article
Language: en
Open access: closed
Locations: Spine (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Orthopedics and Sports Medicine › Spine and Intervertebral Disc Pathology
Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
Keywords: low back pain, physiotherapy referral, primary care, guideline adherence, health care utilization, health care costs, opioid use, imaging utilization, spinal surgery, employer-sponsored health insurance
MeSH terms: Analgesics, Opioid, Diagnostic Imaging, Health Services, Humans, Office Visits, Practice Patterns, Physicians', Primary Health Care, Referral and Consultation, Retrospective Studies, Time Factors, Multivariate Analysis, Linear Models, Logistic Models, Odds Ratio, Drug Costs, Treatment Outcome, Cost Savings, Health Care Costs, Low Back Pain, Orthopedic Procedures, Physical Therapy Modalities, Early Medical Intervention

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Primary Care Referral of Patients With Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs

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