Timing of Physical Therapy Initiation for Nonsurgical Management of Musculoskeletal Disorders and Effects on Patient Outcomes: A Systematic Review.

Current United States practice guidelines suggest an initial “wait and see” approach following onset of musculoskeletal pain, particularly for spinal pain. Several single studies suggest that early compared with delayed initiation PT for musculoskeletal conditions may decrease health costs and improve outcomes. The objective was to compare early and delayed initiation of physical therapy (PT) for individuals with musculoskeletal conditions and assess effects on patient-important outcomes and cost. Methods Medline (Ovid), CINAHL (EBSCO), Web of Science, and PEDro were the data sources. The authors included studies that compared early and delayed initiation of PT for patients with musculoskeletal disorders. Studies were excluded if early and delayed interventions were purposefully distinct. Two independent reviewers abstracted study characteristics, outcomes and determined eligibility and quality through consensus with a third reviewer. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach was used in summary conclusions. Standardized effect sizes (d) and odds ratios (OR) were calculated to assess the strength of effect of early versus delayed PT for each included study. Results 3,855 articles were initially screened, and 14 studies were included. The majority of articles studied low back pain (only two articles studied cervical pain). For spinal pain, there was low quality evidence that early versus delayed PT was associated with decreased cost and decreased frequency of opioid prescriptions, advanced imaging, and surgeries without compromising patient-important outcomes. One subgroup analyzed showed improved function/disability with early PT in an occupational health setting.

Although there were consistent results across studies favoring early PT for decreased cost and medical utilization, quality was limited. Preliminary evidence is suggestive of decreased cost without compromising outcomes with early receipt of PT. The primary limitation of the current research on this topic is in study design. Additional high quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes with early initiation of PT.