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Am Fam Physician. 2018;97(7):475

Clinical Question

Is physical therapy (PT) cost-effective in the initial management of patients with acute low back pain?

Bottom Line

At $30,000 per quality-adjusted life year (QALY) gained, early PT for acute low back pain in primary care is cost-effective by the usual criteria of $50,000 to $100,000 per QALY. However, the magnitude of improvement in quality of life is small and is probably not clinically meaningful. PT is an option to consider if it is not too difficult to find nor too expensive for patients. (Level of Evidence = 3b)


A previous randomized trial compared early PT with delayed referral in primary care patients with acute low back pain. It found better short-term outcomes with early PT, and although the results were statistically significant, the effect sizes did not meet the prespecified criteria for a minimal clinically important difference. There were also no differences at one year. Of note, the PT consisted of only four sessions over four weeks, and the smoking rates were lower than in the general population. In this study, the authors used those results to determine if early PT was cost-effective when considering broader outcomes, such as lost productivity and impact on quality of life. They performed a basic cost-effectiveness analysis, although it is limited by only performing a sensitivity analysis for those patients with complete diary data. The model appears to be fairly simplistic, and was not performed using standard modeling software, such as TreeAge. They found that although early PT results in higher total costs in their adjusted analysis ($1,442 vs. $862 over one year), it was also associated with a small increase in QALYs (0.02) and quality-of-life scores. They calculated an incremental cost-effectiveness ratio of $29,000 per additional QALY, and found a similar $32,058 per QALY using a bootstrapping analysis.

Study design: Cost-effectiveness analysis

Funding source: Government

Setting: Outpatient (any)

Reference:FritzJMKimMMagelJSAscheCVCost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976)2017;42(5):285–290.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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