Joe is a 43-year-old business executive who always has been active and fit, working out regularly three times per week, until he developed right sided back and thigh pain six months ago. He does not remember any single event that caused the pain but noticed that a pain that started in his back steadily grew in intensity and migrated down into the thigh over a period of a month. He had seen his PCP who followed the recommendations of American College of Physicians and American Pain Society.1 He was initially told to remain active, use Tylenol or NSAIDS as needed, maintain good erect postures, and be patient. He had an extreme exacerbation last month and a six-day pack of dexamethylasone eased off but did not abolish the symptoms.

He has been referred to neurology for evaluation. He has had an MRI that demonstrates a moderately sized bulge to the right but nothing definitive. On evaluation his neurological status is normal but his movement patterns are limited in a pattern that would be consistent with mechanical back pain without neural compression. An epidural injection does not appear to be the best option at this time but a referral to physical therapy does. What should be ordered and what outcomes should be expected?

BEST PRACTICES IN PHYSICAL THERAPY
The treatment of pain of spinal origin is more often based on the professional or training bias of the professional prescribing or performing the treatment than techniques supported by strong clinical studies.1-3 This is particularly true for the referral for or the application of physical medicine techniques. Do you: Heat it? Cool it? Extend it? Flex it? Stabilize it? Traction it? Manipulate/mobilize it? Strengthen it? Stretch it? Massage it? Or electrify it? Although all of these approaches have been and still are being used, there is no conclusive support to the use of any of these in the treatment of generic back pain.1-4 One of the difficulties in developing clinically supportable treatment plans is the difficulty in accurately identifying the source of the pain. Even in the presence of what appears to be clear imaging evidence of pathology, it is often difficult to confirm that the abnormality seen in the image is the source of the pain.

If it is difficult to identify the source of the pain in a heterogeneous diagnosis like back pain, it becomes even more difficult to identify appropriate treatment interventions for that heterogeneous clinical entity. As a result, research into the use of specific physical therapy procedures has focused not on treating specific pathologies but in defining specific clusters of symptom patterns and specific examination results that allow the therapist to choose a technique or approach that is most effective for that cluster of signs and symptoms.5,6 The development of clinical prediction rules (CPR) has been used to improve clinical outcomes in the management of back pain. Robin McKenzie was one of the first physical therapists to identify the importance of patterns of symptoms and signs as opposed to pathology in identifying specific exercise and patient instructional approaches for spinal pain. His approach to evaluation and treatment has been well studied and has been shown to be successful in specific categories of mechanical spinal pain.7-11 Fritz, Childs and others have recently expanded the study of CPR's to identify those patterns that may be most appropriate for the specific use of repeated movement exercise, manipulation, stabilization exercise, or traction.12-18

CHOOSING AN APPROPRIATE PATIENT
The patient who can most benefit from physical therapy is the patient who presents with mechanically based low back pain (Table 1).7 Patients with chronic pain, neuropathic pain, and behavioral comorbidities are more complicated to manage and their care may be best handled within a multidisciplinary team approach.1,8,19

Prior to making the referral to PT, it is important to make sure that the patient's presentation does not contain medical problems, Red flags that may contraindicate the use of exercise, mobilization/manipulation, or other procedures. Those problems are listed in Table 2.4,20 The physician should also identify those conditions, Yellow flags listed in chart, that may alter how the therapist works with the patient. Although Red and Yellow flags do not necessarily rule out the use of physical therapy, signs and symptoms potentially indicating their presence must first be cleared in the case of Red flags. The presence of Yellow flags should be indentified as a comorbidity on the referral to alert the therapist to its presence. In addition, Yellow flag patients are much more likely to require a multidisciplinary approach if physical therapy is to be successful.1,4,19

MAKING THE REFERRAL TO PHYSICAL THERAPY
In making a referral for physical therapy it is more important for the referring physician to know the capabilities and practice patterns of the therapist performing the care than to request the performance of specific modalities. The therapist will need the freedom to select the most appropriate care pattern based on the CPRs that best fit the cluster of findings on evaluation. In addition the patient's findings should change with time and the pattern of care should change with it.

How to Choose a Physical Therapist. In making the referral to physical therapy for the management of a low back pain patient, the physician should be looking for and expect the following from the physical therapist:

  1. Care should be an individually designed, CPR-based, behaviorally oriented care plan that emphasizes function and patient responsibility.
  2. Responsibility for care should be rapidly transferred from the therapist to the patient.
  3. Care should focus on changing patient behaviors (improving static and dynamic postures, internalizing locus of control, and reducing fear) and recovering function (ADL, recreational, and work).
  4. Care must include training in prophylaxis, both in developing strategies to prevent future recurrences and training in how to recognize and effectively manage early warning signs of recurrence.
  5. Care should be cost efficient and effective. When an insurer covers PT, it is often accompanied by steep co-pays (up to $50 per visit), monetary caps, or limitations in the number of visits per year, or limitations in the duration of care (e.g., 60 days per condition per lifetime).
  6. Timely and clear communication on the patient status, especially in the presence of unexpected or adverse findings, lack of progress, or lack of compliance. Signs of Sub-optimal Care. Those practitioner and care characteristics that lead to poorer outcomes in the management of LBP are:
  7. Care that involves the use of palliative modalities. The professional literature has shown that the use of thermal modalities, electrical stimulation, and ultrasound are counterproductive to a behaviorally oriented treatment approach and should not be a component of care in the treatment of LBP.1-4
  8. One-fits-all care plans do not recognize the variability of presentation documented in the literature and are not supportable by back pain research.
  9. Care that is not consistently provided by the same therapist leads to poorer outcomes. This includes the varying of therapists on visits or the provision of care by assistants or aids.
  10. Care that is not documented by specific functional outcomes or outcome measures.21
  11. Care that does not focus on patient independence and positive patient behaviors.
  12. A frequency of care that is more determined by habit than patient need. This is typified by seeing the patient three times per week for four to six weeks. Care should be more determined by need than habit.

THE CHANGING PRACTICE OF PHYSICAL THERAPY
The world of Physical therapy has changed rapidly over the past several years.22 Patients and insurers are asking for more efficient and effective care. It is no longer appropriate to use PT as a service that primarily provides palliative care, while the self-limiting nature of the condition follows its course. We know that the vast majority of low back patients will improve whether care is provided or not. There is a need for therapists to be accountable both clinically and financially in the provision of their care. The science of physical therapy has grown rapidly over the past several years. Although there are no definitive answers to the conservative management of low back pain, the clinical literature does provide evidence of what best practices are. The therapist should be following the care models delineated in the literature (Table 4).

John Barbis, MA, PT, OCS operates Barbis Spine Therapy in Broomall, PA.

Steven Mandel, MD is Clinical Professor of Neurology at Jefferson Medical College in Philadelphia.