Received: 5 April 2022 Revised: 15 February 2023 Accepted: 13 March 2023

DOI: 10.1002/pmrj.12984

UPDATED SYSTEMATIC REVIEW—CME

Effect of physical therapy timing on patient-reported

outcomes for individuals with acute low back pain:
A systematic review with meta analysis of randomized
controlled trials

Amy W. McDevitt PT, DPT 1 | Catherine G. Cooper MD 2 |

Jason M. Friedrich MD 2 | Dustin J. M. Anderson MD 3 |
Elizabeth A. Arnold PT, DPT 4 | Derek J. Clewley PT, DPT, PhD 5

1
Department of Physical Medicine and Abstract
Rehabilitation, Physical Therapy Program,
University of Colorado School of Medicine,
Objective: The purpose of this systematic review with meta-analysis was to
Aurora, Colorado, USA investigate the effect of early physical therapy (PT) for the management of
2
Department of Physical Medicine and acute low back pain (LBP) on patient-reported outcomes of pain and disability,
Rehabilitation, University of Colorado School compared to delayed PT or non-PT care.
of Medicine, Aurora, Colorado, USA
3
Literature Survey: Randomized controlled trials in three electronic databases
The Steadman Clinic, Aspen Valley Hospital,
Aspen, Colorado, USA
(MEDLINE, CINAHL, Embase) were searched from inception to June 12, 2020,
4
The Ohio State University, Wexner Medical
and updated on September 23, 2021.
Center, Columbus, Ohio, USA Methodology: Eligible participants were individuals with acute low back
5
School of Medicine, Department of pain. The intervention was early PT compared to delayed PT or non-PT
Orthopaedic Surgery, Division of Doctor of care. Primary outcomes included the patient-reported outcomes of pain and
Physical Therapy, Duke University, Durham,
North Carolina, USA
disability. The following information was extracted from included articles:
demographic data, sample size, selection criteria, PT interventions, and
Correspondence pain and disability outcomes. Data were extracted following Preferred
Amy W. McDevitt, Department of Physical Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Medicine and Rehabilitation, Physical Therapy
Methodological quality was assessed using the Physiotherapy Evidence
Program, University of Colorado School of
Medicine, Aurora, CO 80045, USA. Database (PEDro) Scale. Random effects models were used for the meta-
Email: [email protected] analysis.
Synthesis: Seven of 391 articles met the eligibility criteria and were included in
the meta-analysis. Random effects meta-analysis comparing early PT to non-
PT care for acute LBP indicated a significant reduction in pain (standard mean
difference [SMD] = 0.43, 95% confidence interval [CI]: 0.69 to 0.17) and
disability (SMD = 0.36, 95% CI: 0.57 to 0.16) in the short term. Early PT
compared to delayed PT did not result in improvement in short-term pain
(SMD = 0.24, 95% CI: 0.52 to 0.04) or disability (SMD = 0.28, 95% CI:
0.56 to 0.01), or long-term pain (SMD = 0.21, 95% CI: 0.15 to 0.57) or dis-
ability (SMD = 0.14, 95% CI: 0.15 to 0.42).
Conclusions: This systematic review and meta-analysis suggest early PT
versus non-PT care is associated with statistically significant reductions in
short-term pain and disability (up to 6 weeks) with small effect sizes. The
results indicate a nonsignificant trend favoring a small benefit of early PT over
delayed PT for outcomes at short-term follow-up but no effect at long-term
follow-up (6 months or greater).

1466 © 2023 American Academy of Physical Medicine and Rehabilitation. http://www.pmrjournal.org PM&R. 2023;15:1466–1477.
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MCDEVITT ET AL. 1467

INTRODUCTION METHODOLOGY
Low back pain (LBP) is a highly prevalent and costly Searches and inclusion criteria
musculoskeletal condition worldwide. It is the most
common type of pain and 25% of U.S. adults have Preferred Reporting Items for Systematic Reviews and
had an episode within the last 3 months. 1 LBP is Meta-Analyses (PRISMA) guidelines were followed in
associated with high health care use, medical the development of this systematic review.23 The
expenditure, and reduced quality of life. LBP is also review was prospectively registered with the Interna-
associated with high levels of pain, disability, and tional Prospective Register of Systematic Reviews
years lived with disability.2–4 In 2008, indirect costs (PROSPERO) (CRD42020158144). A comprehensive
associated with the management of LBP in the literature search was conducted with assistance from a
United States were estimated to be $7.4 billion5 with medical librarian in MEDLINE, CINAHL, and Embase
direct costs estimated at $34.2 million with 75% databases from inception to June 12, 2020, and
associated with medical treatment for pain. 6 Further, updated on September 23, 2021. A meta-analysis was
health care costs for individuals with chronic LBP performed when there were more than two studies to
are double that of individuals with acute LBP.7 It is pool data on reported outcome measures for pain
estimated that 75% of direct health services expen- and/or disability. Details on the search strategy can be
ditures can be attributed to 25% of the back pain found in Appendix S1.
population.8 Inclusion criteria for studies in this review were as
When considering the impact of physical therapy follows: (1) study designs were peer-reviewed RCTs;
(PT) on patient outcomes, one must consider that PT (2) study participants were at least 18 years old;
represents a profession with heterogeneous treat- (3) study participants had a newly diagnosed episode
ment approaches and LBP is a heterogenous condi- of LBP within the last 6 months prior to initial presenta-
tion. LBP studies are frequently hampered by a lack tion; (4) the experimental group received early access
of subgrouping and consequently low effect sizes to PT; (5) the comparison group received either
from various treatments.9 Nonetheless, LBP treat- delayed PT or non-PT care; and (6) studies assessed
ment guidelines include recommendations to initiate patient-reported outcomes including pain and/or disabil-
nonpharmacologic treatments commonly delivered in ity. Exclusion criteria included the following: (1) study
a PT practice such as pain education, advice to participants with an episode of back pain that was
remain active, spinal manipulation, exercise, and in chronic or chronicity was not explicitly stated; (2) study
some cases, cognitive behavioral therapy and inter- participants with a prior history of lumbar surgery, red
disciplinary rehabilitation.10–12 Recent studies sup- flag symptoms, or neurologic symptoms; (3) study
port a more stratified approach to LBP care.13–15 investigated only a single PT intervention (which is not
Regarding PT interventions specifically, randomized reflective of clinical practice); (4) study included inter-
controlled trials (RCTs) support a classification- ventions from other disciplines in addition to PT; and
based approach, which improves patient-reported (5) study designs including case reports, editorial or
outcomes through subgrouping patients by physical qualitative studies, systematic review, non-peer
therapist evaluation and subsequently matching each reviewed, or abstract format only.
subgroup with a more specific PT intervention.16,17
Timing of the initiation of PT is another variable
potentially affecting patient outcomes but is not Selection of trials
included in medical treatment guidelines for LBP. Some
studies have reported that patient outcomes are better Retrieved references were exported to an Endnote file
when PT is accessed earlier as compared to non-PT and duplicates were removed. Endnote files were
initial management.18–21 However, drawing firm conclu- uploaded into Covidence,24 an online software
sions from these individual trials is challenging due to designed for screening and reviewing of studies for
variable time points of entry, interventions used, out- systematic review. Titles and abstracts were screened
comes captured, and follow-up periods. In a value independently by two of three authors (C.C., D.A.,
assessment, the timing variable is an important one to A.M.), and a fourth author (D.C.) settled discrepancies.
study with respect to patient outcomes since it has Full-text articles were similarly screened and discrepan-
already been shown that early entry to PT can reduce cies were resolved.
downstream health care use and costs.22 The purpose
of this systematic review with meta-analysis is to better
determine if early access to PT for the treatment of Data extraction
acute LBP is associated with improved patient-reported
outcome measures, including pain and disability, com- Two reviewers (C.C and D.A.) independently extracted
pared to delayed PT or non-PT care. the data and a third reviewer (J.F.) reviewed the
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1468 TIMING OF PHYSICAL THERAPY FOR LOW BACK PAIN

information to ensure accuracy and agreement. Fur- short-term follow-up (which we refer to here as “short-
ther, the third reviewer (J.F.) reviewed to correct data term pain” and “short-term disability”) were estimated
when there was disagreement. The information was by outcomes assessed at 6 weeks post randomization
organized in a table that included study design, partici- or less. Similarly, effects on pain or disability evaluated
pants, timing, PT-based interventions, definitions of at long-term follow-up (which we refer to as “long-term
early PT and comparison groups, and patient-reported pain” and “long-term disability”) were estimated by out-
outcome measures measuring the domains of pain and comes assessed at 6 months or greater. Comparisons
disability. were made for short- and long-term effects. Data for
pain and disability scores were pooled for meta-
analysis using RevMan 5 version 5.4.1. A random-
Operational definitions of acute LBP, early effects model was used for all meta-analyses due to
PT, delayed PT and non-PT care the population variance across studies.29 Due to differ-
ences in the outcomes used across studies, standard
Acute LBP was defined <12 weeks of symptoms. Simi- mean differences (SMD) with 95% confidence intervals
lar to a previous analysis comparing early PT and (CIs) were calculated. Study heterogeneity was repre-
delayed PT, this study defined early PT as any PT initi- sented by the I 2 statistics. Heterogeneity scores were
ated within 30 days of the index visit for LBP.22 The interpreted as high (>75%), moderate (50%–75%), and
term “index date” is used throughout the article to low (25%–50%).30 Effect sizes were interpreted as
describe the date of the first visit for LBP, not the large if greater than 0.8, moderate if between 0.5 and
patient’s recollection of the onset of their first symp- 0.8, and small if between 0.2 and 0.5.31
toms. Delayed PT was defined as the onset of PT after
at least 30 days from the index visit for LBP. Non-PT
care was defined as LBP treatment by a provider other Deviations from the protocol
than a physical therapist. If a physical therapist pro-
vided generic education only without a specific or indi- The original plan was to use the Cochrane Risk of Bias
vidualized PT intervention, then this education was still tool; however, the research team used the Physiother-
considered non-PT care for the purpose of this study. apy Evidence Database (PEDro) methodological qual-
The term usual care can vary in definition across trials ity assessment tool. Further, the original study plan
despite its use as a common comparator in intervention was to include prospective and retrospective cohort
trials for individuals with LBP.25 In the present study, studies; however, the determination was made to
“no care” or “usual care” were also included as non- include only RCTs so that a meta-analysis inclusive of
PT care after ensuring that PT was not provided as part all trials could be reported.
of “usual care.”

RESULTS
Methodological quality assessment
Study selection
Methodological quality was assessed using the PEDro
Scale. The PEDro Scale is a valid and reliable tool The initial search strategy resulted in 391 records, from
developed specifically for RCTs investigating PT man- which seven full texts were assessed. Seven trials were
agement.26,27 The tool includes 11 items and is scored included in the meta-analysis based on the homogene-
out of 10. The first item, study eligibility, is not used in ity of study design and outcome measures used.
the total score. The higher the score the higher the Figure 1 details the flow of the study selection process.
quality of study and less risk of bias. PEDro scores are
scored among trained members of PEDro. These
scores are available to the consumer. This tool was Study characteristics
selected over the Cochrane Risk of Bias tool because it
is specific to PT trials.28 The extracted data from all studies are included in
Table 1. All seven studies were RCTs18,19,21,32–35 with
one being a pilot RCT or feasibility study.18 These RCTs
Statistical analysis had sample sizes ranging from 40 to 220 participants.

A meta-analysis was performed to compare pain and/or

disability outcomes between early PT and delayed PT Methodological quality
and early PT and non-PT care when adequate study
homogeneity was identified. For the purpose of the Methodological quality was variable across studies with
meta-analysis, effects on pain or disability evaluated at scores ranging from 4 to 8 with a maximum possible
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MCDEVITT ET AL. 1469

Records idenfied through database searching (n = 681)

Definitions of early PT, delayed PT, and non-
PT care
Identification
MEDLINE
CINAHL
EMBASE
Six studies reported on the results of early PT initiated
within 48–72 hours of the index date of the first visit for
LBP.19,21,32–35 One study defined early PT ranging from
the primary index date to within 14 days of the index
Records aer duplicates removed (290)
(n = 391)
visit date.18 Although our operational definition of early
PT for study inclusion allowed PT to be initiated up to
30 days following the index visit for LBP, all studies
Screening

Titles and abstracts

included in this analysis initiated early PT within
Records excluded 14 days of the index visit and most did so within
screened
(n = 373)
(n = 391) 72 hours.
Three studies compared early PT to delayed PT;
Full-text arcles excluded, with time windows of initiation of delayed PT were variable
reasons: due to differing study designs and ranged from 4 to
Full-text arcles (n = 11)
6 weeks after the index visit date.18,21,35 Early PT inter-
Eligibility

screened for ∙ 5 wrong study design

eligibility ∙ 3 wrong intervenon vention and delayed PT interventions were the same in
(n = 18) ∙ 2 wrong paent populaon each of the groups across the studies. However, one
∙ 1 wrong comparator
study included a component of advice on the index visit
prior to initiation of a delayed PT hold time of
6 weeks.35
Full-text arcles
included in Four studies compared early PT to non-PT
Included

qualitave synthesis care.19,32–34 Descriptions of non-PT care, often referred

and meta-analysis
(n = 7)
to as usual care in the studies, varied among the four
studies. One study included a 20-minute education ses-
sion on self-management and psychosocial resilience
FIGURE 1 Flow diagram showing study selection. for both groups (PT and non-PT care groups) at the pri-
mary index date.32 Two studies comparing early PT to
non-PT care included the use of the “Back Book”36 and
an education session including reassurance of a favor-
score of 10 (Table 2). The most problematic domains able prognosis and advice to be active, implemented
were the blinding of patients and assessors. Blinding of on the index visit for both groups.19,33 One study pro-
participants and assessors is often difficult in clinical tri- vided nonspecific back massage and standard back
als where the timing of the intervention is being studied. advice to the non-PT care group over the same number
of visits as the early-PT group.34

Summary of the evidence

Pain
Description of PT
Patient-reported outcome measures used to measure
PT interventions included education (staying active and pain varied among studies. Two studies used the visual
avoiding bed rest), exercise and exercise progression analog scale (VAS)18,35 and five studies used the
(including range of motion, spinal stabilization/ numeric pain rating scale (NPRS).19,32,33 In addition to
strengthening and extension-biased exercise if indi- the VAS, Wand and colleagues35 used the usual pain
cated), and manual therapy (including thrust and non- intensity and the Modified Somatic Perception Ques-
thrust manipulation techniques). Four studies included tionnaire (MSPQ). The Borg category scale for ratings
PT interventions that were pragmatic, in other words, of perceived pain and the Orebro musculoskeletal pain
individualized to each patient.18,19,21,35 One study had screening questionnaire were both used by the same
a prescriptive approach with all patients receiving the study.21 The study by Gillan et al.34 did not use pain as
same intervention across the early PT participants.33 a primary or secondary outcome measure.
Two studies included a more prescriptive approach to
intervention initially, followed by a pragmatic approach
after a specified time period or number of visits.32,34 Pain: Early PT versus delayed PT
The number of PT visits ranged from one to eight visits
across studies. Detailed descriptions of interventions Three studies investigated early PT versus delayed PT
used in each study can be found in Table 1. for short- and long-term pain.18,21,35 Reddington et al.
 TABLE 1 Study characteristics
1470

Early PT versus delayed PT

Participants Intervention Outcomes Results
Sample size;
mean age (y) Outcome measure
Study design and SD Participant eligibility Early Delayed follow-up Pain Disability
30
Nordeman et al. n = 60 18–65 years old with PT within 2 days PT after 4 weeks BRPP (pain) RMDQ No significant No significant
Prospective RCT 33.4 subacute LBP (3– PT treatment was PT treatment was (disability) difference in pain from difference in
12 weeks from onset) individualized based on individualized based on Baseline Discharge baseline to discharge disability from
localized to the low history and physical history and physical 6 months was found between baseline to
back with or without LE examination; 1 visit examination; 1 visit groups. Early PT was discharge was
symptoms associated with found between
significantly greater groups. No
reduction in pain, significant
compared to delayed difference in
PT at 6 months. disability from
baseline to
6 months was
found between
groups.
Reddington et al.27 n = 80 >18 years old with PT within 2 weeks PT after 6 weeks VAS (pain) Early PT was Early PT was
Pilot RCT 47 (13.5) unilateral lumbar Individualized, goal- Individualized, goal- ODI (disability) associated with associated with
radicular pain and/or oriented PT based on oriented PT based on Baseline decreased pain up to improved disability
nerve root symptoms interview, PROMs and interview, PROMs and 6 weeks 6 weeks. When the up to 6 weeks.
clinical assessment; 6 clinical assessment; 6 12 weeks delayed PT group When the delayed
visits over 8 weeks visits over 8 weeks 26 weeks began their PT at PT group began
6 weeks, the rate of their PT at
recovery assimilated 6 weeks, the rate
and by 12 weeks, both of recovery
groups had similar pain assimilated and by
levels. 12 weeks, both
groups had similar
function.
Wand et al.35 n = 94 20–55 years old with acute PT within same day PT after 6 weeks VAS (pain) Early PT was not Early PT was
Prospective RCT 35 (8.5) LBP <6 weeks referred Advice on staying active Advice on staying active RMDQ (disability) associated with associated with
to physical therapy and “Back Book.” and “Back Book” on Baseline significant significant
Pragmatic, evidence- index date. Pragmatic, 6 weeks improvements in pain at improvements in
based approach evidence-based 3 months 6 weeks. After 3 and disability at
including manual approach including 6 months 6 months, pain was not 6 weeks. After 3
therapy (low velocity manual therapy (low significantly different and 6 months,
mobilization and high velocity mobilization between groups. disability was not
velocity manipulation), and high velocity significantly
rehabilitation exercises manipulation), different between
including ROM and rehabilitation exercises groups.
strength, advice on including ROM and
staying active and strength, advice on
TIMING OF PHYSICAL THERAPY FOR LOW BACK PAIN

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 TABLE 1 (Continued)
Early PT versus delayed PT
Participants Intervention Outcomes Results
MCDEVITT ET AL.

Sample size;
mean age (y) Outcome measure
Study design and SD Participant eligibility Early Delayed follow-up Pain Disability

education; number of staying active and

visits not described. education; number of
visits not described.
Fritz et al.16 n = 220 18–60 years old with no PT within 72 h No PT NPRS (pain) Early PT was not Early PT was
Prospective RCT 37.4 (10.3) LBP treatment in the Received education about Received education about ODI (disability) associated with a associated with a
past 6 months, ODI the favorable prognosis the favorable prognosis Baseline significant improvement significant
score ≥20, symptoms of LBP and a copy of of LBP and a copy of 4 weeks in pain intensity at improvement in
duration <16 days, and the “Back Book.” PT the “Back Book.” 3 months 4 weeks, 3 months, and disability at
no symptoms distal to included prescriptive 1 year 1 year. 4 weeks and
the knee in the past approach including 3 months, but not
72 h spinal manipulation, 1 year.
spinal ROM exercises,
trunk strengthening and
exercise progression; 4
visits over 3 weeks.
Fritz et al.28 n = 220 18–60 years old with PT within 72 h No PT NPRS (pain) Early PT resulted in Early PT resulted in
Prospective RCT 39 (11.2) sciatica, ODI score ≥20, Received education about Received education about ODI (disability) significantly greater significantly greater
symptoms present the favorable prognosis the favorable prognosis Baseline improvements in pain improvements in
90 days or less, and of LBP and a copy of of LBP and a copy of 4 weeks intensity at 4 weeks, disability, at
symptoms distal to the the “Back Book.” PT the “Back Book.” 3 months 6 months, and 1 year. 4 weeks,
knee in the past 72 h included pragmatic 1 year 6 months, and
approach including 1 year.
manual therapy
(mobilization and high
velocity manipulation)
and exercise including
instruction in HEP; 6–8
visits over 4 weeks.
Gillan et al.34 n = 40 Back pain less than PT within 1 week No PT ODI (disability) NA No significant between
Prospective RCT 29–58 12 weeks in duration McKenzie management; No physical intervention Baseline (day 1) group differences
and with a presence of standard protocol except for nonspecific 28 days in disability at any
a lateral shift (prescriptive); 2–3 back massage and 90 days time point.
visits/week for 1 week standard back advice;
then at PT discretion 2–3 visits/week for
(pragmatic). 1 week then at PT
discretion.
Rhon et al.32 n = 119 18–60 years old military PT within 72 h No PT NPRS (pain) There was no Early PT was
Prospective RCT 27.2 (6.5) service members with 20-min educational session 20-min educational session ODI (disability) difference in the NPRS associated with
focusing on evidence focusing on evidence Baseline significantly lower
(Continues)
1471

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1472 TIMING OF PHYSICAL THERAPY FOR LOW BACK PAIN

demonstrated significant reductions in pain between

at 4 weeks, but not

groups (measured by the VAS) at 6 weeks.18 Norde-

levels of disability

Abbreviations: BRPP, Borg category scale for ratings of perceived pain; HEP, home exercise program; LE, lower extremity; LBP, low back pain; NPRS, numeric pain rating scale; ODI, Oswestry disability index; PROMs,
man et al.21 did not report differences in pain at patient

patient-reported outcome measures; PT, physical therapy; PTs, physical therapists; RCT, randomized control trial; RMDQ, Roland and Morris disability questionnaire; ROM, range of motion; TBC, treatment-based
discharge; however, the authors did report a significant
difference in pain between the early and delayed PT

1 year.
Disability
groups at 6 months favoring early PT. Similarly, Wand
et al.35 demonstrated between-group differences in
pain at 6 months as measured by the MSPQ. When
results of RCTs were pooled, no effect was found for
short-term pain (SMD = 0.24, 95% CI: 0.52 to 0.04)
at any of the time

or long-term pain (SMD = 0.21, 95% CI: 0.15 to

0.57), (Figure 2A, B).
Results

points.

The TBC approach attempts to match a patient with an appropriate treatment based on their clinical presentation and relevant impairments based on examination findings.
Pain

Pain: Early PT versus non-PT care

Outcome measure

Three studies investigated early PT versus non-PT

care for short- and long-term pain.19,32,33 The study by
Outcomes

Rhon et al.32 did not show a difference on the NPRS at

follow-up

3 months
4 weeks

1 year

all time points (4 weeks, 3 months, 1 year). Two studies

by Fritz et al. found significant between-group differ-
ences in pain as measured by the NPRS at
4 weeks,19,33 3 months,33 6 months, and 1 year.19
management of LBP.

When results were pooled, a small effect (SMD = 0.43,

95% CI: 0.69 to 0.17) was found favoring early PT
based self-

for short-term pain. No effect was found for long-term

pain (SMD = 0.15, 95% CI: 0.40 to 0.09),
Delayed

(Figure 3A, B).

of a TBC approach PTs
therapy, exercise, or an

program. After 2 weeks

Disability
management of LBP.

patients were treated

pragmatic approach;
including manual

extension-based

Measures of disability across studies included the

TBCa approach

could follow a

up to 8 visits.

Oswestry Disability Index (ODI) and the Roland and

based self-
Intervention

Morris disability questionnaire (RMDQ). Five studies

used the ODI18,19,32–34 and two studies used the
RMDQ to measure disability.21,35
Early

duration and ODI >20

Disability: Early PT versus delayed PT

Participant eligibility

LBP <90 days in

Three studies investigated early PT versus delayed PT

Early PT versus delayed PT

for short- and long-term disability.18,21,35 The study by

Reddington et al.18 demonstrated improvement in the
ODI in the early PT group up to 6 weeks; however, both
groups had similar outcomes by 12 weeks. Similar find-
ings were reported by Wand et al.35 with improvement
mean age (y)
Sample size;

classification; VAS, visual analog scale.

Participants

in disability as measured by the RMDQ (compared to

the delayed PT group) at 6 weeks, but with no signifi-
and SD
(Continued)

cant differences between groups at 3 and 6 months.

Nordeman et al.21 measured disability with the RMDQ
and reported no significant differences between groups
at discharge and at 6-month follow-up. When results
Study design

were pooled, no effect was found for short-term disabil-

TABLE 1

ity (SMD = 0.28, 95% CI: 0.56 to 0.01) or long-term

disability (SMD = 0.14, 95% CI: 0.15 to 0.42),
(Figure 2C, D).
a
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MCDEVITT ET AL. 1473

TABLE 2 Methodological Quality

Physiotherapy Evidence Database (PEDro)

Total score/10 (Eligibility does not contribute to total
Study 1 2 3 4 5 6 7 8 9 10 11 score)

Fritz et al.16 Y Y Y Y N N Y Y Y Y Y 8
Fritz et al.28 Y Y Y Y N N Y Y N Y Y 7
34
Gillan et al. Y Y N Y N N Y N N Y N 4
Nordeman et al.30 Y Y Y N N N N Y Y Y Y 6
Reddington et al.27 Y Y N Y N N N Y N Y Y 5
Rhon et al.32 Y Y Y Y N N N Y Y Y Y 7
Wand et al.35 Y Y Y Y N N Y N Y Y Y 7
Note: PEDro items indicated whether the study clearly described the following topics: 1. Eligibility was specified. 2. Participants were randomly allocated. 3.
Allocation was concealed. 4. Groups were similar at baseline. 5. Participants were blinded. 6. Therapists were blinded. 7. Assessors were blinded. 8. Measures of
one key outcome were obtained from more than 85% of the initial allocated group. 9. All participants were available and received treatment or control as allocated or,
if not the case, were analyzed by “intention to treat.” 10. Results of between-group statistical comparisons are reported for at least one key outcome. 11. Study
provides both point measures and measures of variability for at least one key outcome.

Disability: Early PT versus non-PT care short-term pain and disability (up to 6 weeks) with
small effect sizes. No effect was found for pain or dis-
Three studies investigated early PT versus non-PT ability at longer follow-up time points.
care for short- and long-term disability.19,32,33 Three The following sections aim to better explain these
prospective RCTs demonstrated significant between- findings, interpret the findings in the context of a value
group differences on the ODI at 4 weeks19,32,33 with equation, and highlight clinical implications, limitations,
significant improvement in disability and function and future directions for research.
between groups at 3 months33 and 6 months.19 One
study demonstrated significant effects on disability at
1 year favoring early PT.19 Rhon et al.32 did not demon- Early PT versus delayed PT
strate between-group changes at 1 year; however,
there was a significant improvement from baseline to This meta-analysis shows that early PT after an epi-
1 year within groups on the ODI. Gillan et al.34 also sode of acute LBP resulted in a nonsignificant trend
reported improvement within groups, as measured by towards a reduction in pain and disability compared to
the ODI; however, there were no significant differences delayed PT in the short term, but no long-term effects
between groups at 28- and 90-day follow-up. Pooled were seen.18,21,35 The individual studies included in this
results demonstrated a small effect (SMD = 0.36, 95% analysis did demonstrate significant improvements in
CI: 0.57 to 0.16) that favored early PT for short-term pain (between groups) up to 6 weeks18 and disability
disability. No effect was found for long-term disability up to 6 weeks18,35 but the effects were small and it is
(SMD = 0.19, 95% CI: 0.39 to 0.02), (Figure 3C, D). possible that rates of recovery were similar between
groups by the long term.18,35 One study reported
decreased pain in the early PT group compared to
DISCUSSION delayed PT at 6 months; however, the effects were small
and the description of the intervention was limited.21
The purpose of this systematic review with meta- Additionally, interventions between early PT and
analysis was to determine if early access to PT for delayed PT groups were pragmatic and variable, poten-
the treatment of acute LBP is associated with tially washing out any significant effect. Continued efforts
improved patient-reported outcomes including pain toward appropriate patient subgrouping and matched
and disability compared to either non-PT care or treatment protocols in prospective studies will improve
delayed PT. We identified seven prospective future investigations of early versus delayed PT.16,37
RCTs18,19,21,32–35 evaluating early PT versus
delayed PT or non-PT care in individuals with acute
LBP and all seven trials were included for meta-anal- Early PT versus non-PT care
ysis. Our results indicate a nonsignificant trend favor-
ing a small benefit of early PT over delayed PT for Compared to non-PT care, early PT led to short-term
outcomes at short-term follow-up, but no effect at improvements in pain and disability but showed no dif-
long-term follow-up. Early PT versus non-PT care is ference long term. Exactly what components of PT led
associated with statistically significant reductions in to early improvements is not clear from this analysis.
 19341563, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12984 by Readcube (Labtiva Inc.), Wiley Online Library on [11/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1474 TIMING OF PHYSICAL THERAPY FOR LOW BACK PAIN

FIGURE 2 Early physical therapy versus delayed physical therapy. CI, confidence interval; PT, physical therapy; Std., standard.

PT interventions were performed and the number of tools may be helpful in directing the intensity of PT care
visits varied across studies. Guideline-adherent early provided to patients with acute LBP.13–15 An additional
PT for LBP traditionally emphasizes acute pain man- consideration is the lack of an active comparator group
agement through manual therapy with postural correc- when using a non-PT control, as well as the difficulty in
tions, pain education, and reassurance38 which may blinding patients. This can potentially lead to short-term
have less effect on patient-reported outcomes in the benefits but the effects of treatment would likely dimin-
long term. Alternatively, certain patient subgroups, such ish over time.
as those with sciatica, may see longer-lasting improve-
ment with early PT than others.19
The lack of significant long-term differences in the Clinical implications
current analysis may also be explained by the early
education and advice to stay active dispensed to both This review suggests that early PT when compared to
groups in the included studies.19,32–34 Some subgroups non-PT care may lead to a greater reduction in pain
of individuals with LBP benefit from just one session of and disability up to 6 weeks following initiation of care;
education and advice about medication, work, and however, the effects between groups was small. With
activity.14,15,33 Patient stratification using screening respect to pain and disability scores, early PT does not
 19341563, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12984 by Readcube (Labtiva Inc.), Wiley Online Library on [11/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MCDEVITT ET AL. 1475

FIGURE 3 Early physical therapy versus non-physical therapy care. CI, confidence interval; PT, physical therapy; Std., standard.

appear to be superior to non-PT care or delayed PT to the population variance, which will appropriately
care beyond 6 months. decrease the effect size. More studies with improved
subgrouping of LBP populations may provide more
clarity regarding the overall effect of early versus
Strengths and limitations delayed PT. Another limitation is that two of the studies
that demonstrated a significant finding favoring early
This systematic review has some strengths. Most nota- PT are from the same authorship team.19,33 However,
bly the authorship team followed methodological stan- the samples are distinct and the methods are unique to
dards for systematic reviews with meta-analysis. the aim of each of those studies.
However, this review also has limitations. The small Further, the varying risk of bias scores may have
number of RCTs and the underpowering of studies affected fidelity of the results. To that point, blinding to
included in the analysis affect their ability to detect early versus delayed or non-PT care in the context of
change. LBP is not homogenous. The population vari- an RCT is generally not possible, thus affecting risk of
ance across studies is another limitation. Inconsistency bias scores and introducing potential bias toward find-
in the type of LBP and the population studied ing a beneficial effect of PT. The homogeneous nature
decreases the overall impact of the results. We used a of the data reporting allowed for pooling of data for
random-effects model versus a fixed-effects model due meta-analytic procedures yet the heterogeneity of the
 19341563, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12984 by Readcube (Labtiva Inc.), Wiley Online Library on [11/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1476 TIMING OF PHYSICAL THERAPY FOR LOW BACK PAIN

interventions (including a lack of a consistent definition 2. Bevan S. Economic impact of musculoskeletal disorders (MSDs)
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