J. Zadro1, A. Lewin2, P. Kharel1, C. Maher1, I. Harris2,1
1The University of Sydney, Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, Camperdown, Australia, 2University of New South Wales, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, Sydney, Australia

Background: Clinical practice guidelines for low back pain typically recommend against spinal fusion surgery and only recommend spinal decompression surgery for people with neurological symptoms and when non-operative management has ‘failed’. A key challenge in deciding whether a patient is suitable for surgery is determining what constitutes ‘failed’ non-operative management. Guidelines vary in their recommendations for how long patients with low back pain should receive non-operative management before considering surgery, ranging from 4-6 weeks to 2 years. Understanding how much physiotherapy patients receive before lumbar spine surgery could give insight into what patients and clinicians consider an adequate trial of non-operative management. No study has investigated how much physiotherapy patients receive – and for how long – from initiation of physiotherapy to lumbar fusion and lumbar decompression surgery, in Australia, or in a setting involving workers’ compensation.

Purpose: To investigate physiotherapy utilisation before lumbar spine surgery under a worker’s compensation claim in Australia.

Methods: Using data from the NSW State Insurance Regulatory Authority, we audited physiotherapy billing codes used before surgery for patients who received lumbar spine surgery from 2010-2018. We summarised, separately for fusion vs. decompression, the time from initiation of physiotherapy to surgery, number of physiotherapy sessions patients received before surgery, total cost of physiotherapy before surgery, and time from injury date to initiation of physiotherapy. All analyses were descriptive.

Results: We included 3,070 patients (800 had fusion; 2,270 decompression). Mean age (standard deviation, SD) was similar between those who received fusion and decompression [42.9 (10.4) vs. 41.9 (11.6)]. Compared to patients who had fusion, those who had decompression were more likely to not have physiotherapy before surgery (28.4% vs. 15.4%), received physiotherapy for less time before surgery [median (interquartile range, IQR): 5 (3 to 11) vs. 15 (4-26) months], were less likely to have physiotherapy for ≥2 years before surgery (5.6% vs. 27.5%), had fewer physiotherapy sessions before surgery [mean (SD): 16 (21) vs. 28 (35) sessions], were less likely to have >50 physiotherapy sessions before surgery (6.8% vs. 18.1%), and had lower total physiotherapy-related costs [mean (IQR): $1,265 ($0-1,808) vs. $2,357 ($453-2,947)]. Time from injury date to first physiotherapy session was similar between patients who had fusion and decompression [median (IQR): 23 (9-66) vs.19 (7-53) days].

Conclusion(s): There is variation in physiotherapy utilization before lumbar spine surgery for patients funded by NSW Workers’ Compensation in Australia. Some patients do not appear to receive an adequate trial of physiotherapy before surgery, particularly before decompression surgery. Others receive a large amount of physiotherapy before surgery, particularly before fusion.

Implications: To improve physiotherapy practice, future research should determine “how much” non-operative management is adequate before lumbar spine surgery, considering time from initiating non-operative treatment to surgery and volume of non-operative treatment. Future work is also needed to better understand what physiotherapy-delivered treatments patients try before deciding to have lumbar spine surgery in settings involving worker’s compensation, as well as in other settings and for other conditions.  

Funding, acknowledgements: This study did not receive funding. 

Keywords: rehabilitation, physical therapy, lumbar spine surgery

Topic: Musculoskeletal: spine

Did this work require ethics approval? Yes
Institution: South Western Sydney Local Health District
Committee: Research Ethics Office
Ethics number: HREC/16/LPOOL/189

All authors, affiliations and abstracts have been published as submitted.

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