Back Pain: Why Direct Access To Physical Therapy Is A Critical Consumer Issue

If there was ever a reason for Direct Access to Physical Therapy to exist – in ANY state of the US or country of the world – it would be back pain. There is no doubt that back pain could become the poster child for this consumer initiative. It also provides plenty of evidence-based reasons to counter the claims of physician naysayers.

First things first – back pain will affect 50 - 80% of the population at some point in their lives, and 40% of the population will have an episode of back pain within any given year. This amounts to about 31 million Americans that are afflicted with low back pain at any given point in time, or approximately 10% of the population.

The estimated costs of back pain in the US exceed $170 billion annually. Yes, that is BILLIONS of dollars.

In the world of back pain, evidence-based practice (via clinical practice guidelines) is going to be critical in order to increase access to care and to decrease the cost of care. I would like to think that physicians, chiropractors, and physical therapists alike would agree on this. So let’s try to weed out “conjecture” from “data” as it applies to the claims regarding back pain and patient direct access to physical therapy.

Physician claim: Physical therapists “can’t make a diagnosis”.

Well, frankly, most clinicians assessing a patient with back pain – physicians or otherwise - are unable to do so. That’s not an opinion, that’s a well-documented and evidence-based clinical research issue. The vast majority of patients suffering from back pain do not have an actual patho-anatomical diagnosis. Yes, they have signs and symptoms related to mechanical loading and activities of daily living, but most do not have a specific tissue (i.e muscle, etc) that is affected. From a purely diagnostic perspective, the health professions (as a whole) are at a loss to establish the root anatomical cause of most cases of back pain.

Physician claim: Physical therapists “don’t perform imaging studies”.

That is a statement of fact: no, physical therapists do not prescribe imaging studies such as x-rays or MRIs. But the part that is conveniently forgotten (or ignored) is that imaging studies are not the first line of assessment in any clinical guidelines related to back pain. A whopping 70% of people without symptoms have abnormal MRIs of the lumbar spine anyways! Regardless of the provider involved, imaging is not indicated for the vast majority of patients in the initial assessment of an episode of back pain.

Physician claim: Physical therapists “need to have a medical diagnosis to treat”.

Isn’t it interesting that they are conveniently forgetting that most referrals from physicians to physical therapists arrive bearing a simple “Evaluate and Treat” anyways. As mentioned above, most patients simply don’t have a patho-anatomical diagnosis to begin with – so we better get on with understanding the patient’s level of function, a task that is specifically within a physical therapist’s scope of practice.

Physician claim: Physical therapists “want to practice like they are doctors”.

Physical therapists simply want to be able to practice within their current autonomous scope of practice for the benefit of the consumer. Physical therapists will perform a mechanical assessment on a patient to safely assess symptomatic responses to mechanical stresses. They screen for red flags. If a patient presents with signs and symptoms that are inconsistent with a mechanical problem, they are referred to an appropriate provider to perform further assessment that is out of the scope of practice of a physical therapist. Simple. This is mandated in the current scope of practice and would not change if patients had direct access to physical therapy.

Physician claim: Patient safety may be at risk with direct access to physical therapy.

Patient safety starts with listening to the patient. A physical therapist may spend anywhere from 30 minutes to an hour performing an appropriate clinical history and examination. The current data would indicate that a physician spends a total of 10.7 minutes in direct face-to-face time with the patient (1). If we continue to look at the evidence related to patient management for physicians, we find that listening to the patient is critical for physicians to make a proper diagnosis (2, 3). Taking a good patient history alone predicts the diagnosis in 76 - 82.5% of patients, with the physical examination contributing an added 8.7 - 12%, and laboratory investigation needed in another 8.7 - 11%. If a good patient history is so critical, then once again we are left with the question: where is the safety issue with direct access to physical therapy when they actually spend time listening to the patient?

If safety is a true concern, then it would be unconscionable for physicians to propose that massage therapy is a reasonable first line of assessment for back pain while physical therapy is not. Both deal with back pain on a regular basis.

Physician claim: Direct access to physical therapy could cost the patient more money because of over-utilization.

Consider a simple fact – at least one copay or assessment fee would be eliminated for every patient that went directly to a physical therapist. Let’s take just half of those with back pain – 15 million or so – and charge them $100 – 200 minimum for an office visit. That is a $1.5 - $3 billion bill to simply get a piece of paper that says “back pain - evaluate and treat”. How about all of the unnecessary imaging studies performed? That’s about $1500 per MRI. Go ahead, do the math, then read on.

When there are more than 20,000 lumbar spinal fusions performed annually in the United States - eight times as many spinal surgical procedures in the United States per capita as in Britain – should we really be having a discussion about over-utilization of services? How about the fanciful fact that there is also a direct relation between the number of spinal operations performed in any one area and the number of orthopaedists and neurosurgeons? That being the case, the likelihood of you having surgery prescribed for you is related more to the demographics of your locale than it is to "getting the patient better". And while we're at it - for those who want more numbers - the cost of a spinal fusion comes in around $45,000. As for failed spinal surgeries, the numbers are staggering as well - a cost of $2 billion per year. Or perhaps it would be of value to consider the growing rate of physician practice ownership of the imaging equipment for “patient convenience”.

Physical therapy over-utilization isn’t the problem here.

Reality check: The reality of back pain, based on current clinical best practices, is that there is generally no patho-anatomical diagnosis and that imaging studies are not indicated. Most clinical guidelines focus on some simple elements for assessment and treatment of back pain. They include patient education, no more than 1 –2 days of bed rest, and a gradual return to normal activities and recreation. Notice that you did not see any imaging or expensive medical procedures. The greater problem is that back pain is typically recurrent, thus any effective long-term strategies must include patient education.

So that leaves us with mechanical testing procedures as a means of evaluating a patient’s function relative to their episode of back pain – and who better to perform these than physical therapists, the internationally accepted experts in therapeutic exercise prescription.

We also have to acknowledge that patients with back pain have probably already sought out various treatments on the internet and have attempted many on their own without any clinical supervision or guidance whatsoever. Is this a better option than having direct access to a physical therapist who can then screen out red flags, assess to see if movement is indicated or not, and move forward with patient safety and education in mind? Once again, who better to lead “movement” than the international leaders in therapeutic exercise prescription?

Seeing a physical therapist as a first line of health care is an accepted standard internationally, in many other U.S. states - and even within our own military. But not in Texas, nor 32 other states.

The talk of “patient-centered health care” is hypocritical at best. In a patient-centered system, patients have the right to choose their providers. They have access to care. In this era of information, the consumer can decide what is appropriate for them – and the clinician can guide them appropriately. In Texas, you can see just about anyone as a first line of assessment – chiropractor, physician, massage therapist, acupuncturist, even an unlicensed personal trainer – but you cannot see a physical therapist in the same fashion.

Do not be swayed by the conjecture, fear-driven stance and selective attention on “issues” that move your thoughts away from the true issues of consumer access and cost. Evidence will always be the best guide moving forward in a patient-centered health care system. Direct access to physical therapy has worked internationally, and it can work in Texas (and throughout the United States) as well.

(1) Gottschalk A and Flocke SA. Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room. Ann Fam Med. 2005 November; 3(6): 488–493. [citation]

(2) Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975 May 31;2(5969):486-9. [citation]

(3) Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992 Feb;156(2):163-5. [citation]

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