Success of Staffing Patterns in the Treatment of Low Back Pain
Does it matter if you see a physical therapist versus a physical therapist assistant for treatment of your low back pain (LBP)? Do you need to see a specialist within the physical therapy field? For example, is it better to see someone who has expert training in the treatment of low back pain? Or can a generalist help you get the same good results?

These are some of the questions posed by physical therapists in this study. They looked at whether the practice setting was linked with outcomes. They identified service delivery that had the best results. Service delivery referred to who saw the patient and how much time was spent with each one. And they considered whether or not the number of staff members at each clinic made a difference.

All data came from a data bank called Focus on Therapeutic Outcomes (FOTO). FOTO is the largest database containing information on outpatient rehabilitation patients and the results of their physical therapy treatment. Researchers use this international medical rehab data to study various aspects of healthcare.

Their sample was taken from 114 outpatient clinics employing 1,058 physical therapists. Only patients with LBP were included. Over a one-year period, there were 16,281 LBP patients who qualified for this study. Diagnoses included herniated disc, spinal stenosis, spondylosis, pain, and sprain or strain. Most of the patients had not had any surgery for their back problem.

All patients had completed a survey called the Short-Form-36 (SF-36). The SF-36 is a reliable tool that measures general physical and mental health. FOTO is then able to take all information into consideration and calculate the overall health status measure (OHS).

Eight functional scales are included in the OHS. These include general health, physical function, pain, vitality, mental health, emotional status, social function, and upper extremity impairments.

The researchers also looked at a variety of other factors. Size of the professional staff, ratio of physical therapists to physical therapist assistants, years of experience, and level of training were considered. Volume of patients seen in each clinic by each therapist was calculated. The portion of this made up of low back pain patients was also figured. Amount of time spent with individual patients by each therapist or assistant was reported. These last two variables made up a category called measure of utilization.

Scores were used to determine provider performance. Using these residual scores, clinics could be broken down into three groups based on patient results (effectiveness). Each clinic was given a low, middle, or high effectiveness rating.

Clinics with low or middle effectiveness (poor outcomes) and high health care utilization (many visits) had the worst performance. This means patients were seen many times by the staff but had poor results. High effectiveness (good results) with low utilization (few visits) was classified as best performance clinics.

What they found was that patients who saw a physical therapist assistant had the worst results. Patients who saw the therapist had the best results. The more patients with LBP seen at the clinic, the better the results. And the number of visits was lower when patients were treated by the physical therapist (versus the assistant).

The authors conclude that patients with low back pain get less effective care when treated by a physical therapist assistant. This supports results of other studies that show lower functional outcomes for LBP patients treated by an assistant. Higher volumes of patients results in more efficient (fewer visits), but not necessarily more effective care.
Linda Resnik, PT, PhD, OCS, et al. Predictors of Physical Therapy Clinic Performance in the Treatment of Patients with Low Back Pain Syndromes. In Physical Therapy Journal. September 2008. Vol. 88. No. 9. Pp. 989-1004.