routine pain-related psychological distress monitoring
throughout the early phases of rehabilitation espe-
cially if the goal is to identify risk for subsequent
pain-related healthcare utilization. The implications of
these collective findings are that treatment pathways
may provide greater value by 1) addressing modifiable
health-related variables like pain, disability and
pain-related psychological distress, 2) routine moni-
toring of these health-related variables and 3) offering
treatment alternatives that safely escalate care if
needed while minimizing risk of harm and unhelpful
utilization.
Opioids and diagnostic tests and imaging were the two
most common subsequent healthcare services utilized
following physical therapy. Of the individuals that com-
pleted follow up and had any subsequent healthcare
utilization, approximately 42% reported opioid use and
70% reported use of diagnostic tests and imaging. An
important health-related predictor of these services was
level of comorbidity burden. For those with high comor-
bidity burden and inadequate treatment response to
physical therapy, use of additional diagnostic tests and
imaging or low-dose opioids may be appropriate in some
cases. But given the growing public health concern over
opioid use and the desire to avoid unnecessary treat-
ment driven by imaging, our results suggest the import-
ance of considering disease burden when developing
treatment pathways and healthcare policy to mitigate
risk for avoidable use of these services. Interestingly,
neither versions of the OSPRO-ROS predicted
utilization outcomes even though it has been linked to
mental health, comorbidity, a nd persistent pain state in
other analyses [ 20, 21]. Systemic symptom burden is a
measure of patient complexity that is related to but dis-
tinct from comorbidity burden [ 36, 47]. In these ana-
lyses, the chronic condition measure (i.e. the CCI) was
a better predictor of utilization than symptom burden
(i.e. OSPRO-ROS). The reasons for this finding are un-
clear but may be related to providers and patients being
m o r el i k e l yt op u r s u ef o l l o w - u pm e d i c a lc a r ef o rm u s -
culoskeletal pain when known co-existing conditions
are present as opposed to reporting of symptoms alone.
The distinction between symptom and disease burden
in defining musculoskeletal patient complexity, and its
influence on clinical decision-making and outcomes,
should be the subject of future research particularly re-
lated to aging populations [ 48].
Utilization outcomes benchmarks have not been estab-
lished to determine how the percentage of subsequent
healthcare use in this study compares to outcomes using
other health services. Prior studies suggest physical ther-
apy is associated with reduced incidence of additional
healthcare use compared to not using physical therapy
in patients with acute low back pain [ 10, 49]. Some
additional healthcare use is expected following physical
therapy, especially among individuals that are on
long-term pain management pathways due to chronic or
persistent symptoms. Yet with over 40% reporting subse-
quent pain-related healthcare among those completing
follow-up, it is apparent that opportunities exist to im-
prove pathway selection and/or the effectiveness of
physical therapy for individuals with musculoskeletal
pain. This finding is particularly notable given recent
efforts to define physical therapy as an effective first line,
non-pharmacological treatment option against more
invasive or higher risk services, such as surgery or opioid
use, respectively. Predictive variables identified in this
analysis can be used to develop risk models that better
inform pathway selection for those seeking physical ther-
apy for musculoskeletal pain. The precise application of
these risk models, and how they inform policy and prac-
tice should be the target of future study. However, phys-
ical therapy re-design might incorporate enhanced