Dear Editor

Dear Editor: 

The myths described in Overcoming Patient Misbeliefs (PT in Motion, December 2015- January 2016) are ubiquitous in the realm of musculoskeletal medicine, and many are  reinforced by the clinicians patients seek for help.  

Dr. Steven Woolf, MD, MPH speaks also to this issue in an editorial titled The Price of  False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis1 

Patients often receive mixed messages and mis-information about musculoskeletal  problems that are not grounded in science or supported by research. The ability to  diagnose or identify an anatomical pain generator for most patients with NSLBP (non specific LBP) is a prime example. When these patients are told by one caregiver, that  an MRI may be required it is very difficult to convince them that research shows it will  not likely provide any meaningful information and may lead to harms2. 

Patients often present with clear misunderstandings about mechanical factors and LBP as quoted from the referenced article: 

Mechanical factors have long been thought to have a causal role in low back pain.  However, eight systematic reviews with the Bradford-Hill causation criteria concluded  that it was unlikely that occupational sitting, awkward postures, standing and walking,  manual handling or assisting patients, pushing or pulling, bending and twisting, lifting, or  carrying were independently causative of low back pain in the populations of workers  studied.3 

These myths if not properly addressed can promote illness behavior, described  succinctly by Gordon Waddell, MD. Below are some excerpts from a book of his:4 

Illness behavior does not happen: it is learned. It is not fixed, but is a dynamic process  over time, and health care may play a key role in its development. The information and  advice we give may color patients’ beliefs about their illness and what they should do  about it. Traditional treatment of back pain was often direct advice to stop or restrict  normal activities and to behave in a more ill manner. We may prescribe sick  certification……………………………………………………………………………………… …………….. Chronic pain patients often have repeated consultations and examinations  and learn what to say and to do for health professionals. They learn what to expect,  and what is expected of them, and this modifies how they react and behave. Conflicting  opinions and advice, all lead them to press their case more strongly. We teach, and  they learn, illness behavior in their clinical presentation. All of this is unconscious,  learned behavior. Sadly, traditional health care for back pain may have done more to  cause than to prevent illness behavior.

……………………. Illness behavior must not lead to moral judgments or to rejecting  these patients. It is our job as health professionals to care for our patients, both their  physical disorders and their illness behavior. The aim of recognizing illness behavior is  to manage them more appropriately. 

These patients may require both physical treatment of their physical problem and  more careful management of the psychosocial and behavioral aspects of their illness. 

Health care may have a profound influence on illness behavior  

It is often far easier for the healthcare giver (and more profitable for the system) to  “medicalize” an issue and provide interventions that are not likely to be helpful or  promote the ongoing illness behavior. A concerted effort in education of providers,  employers and citizens is required to truly promote a healthy lifestyle and control our  escalating healthcare costs that are not leading to better outcomes or health. 

The Choosing Wisely Campaign cited by Dr. Woolf is very encouraging, and we can  thank Howard Brody MD, PhD for setting the tone for that initiative.5 Dr. Woolf states it  well in his editorial: “The best way to reduce wasteful spending is to convince the  purchaser that the product is not worth buying. It is a straightforward economic  argument, but it can also save lives.” 

Edward L. Scott PT, DPT, OCS 

December 18, 2015 

1 Woolf, S. The Price of False Beliefs: Unrealistic Expectations as a Contributor to the Health Care Crisis. Ann Fam Med 2012;10(6). 

2 Chou R; Qaseem A; Owens DK; Shekelle P: Diagnostic Imaging for Low Back Pain:  Advice for High-Value Health Care from the American College of Physicians. Ann Intern  Med. 2011;154:181-189 

3 Balagué F, Mannion AF, Pellisé F, Cedraschi C Non-specific low back pain. Lancet  2012; 379: 482–91 

4Waddell G. The Back Pain Revolution. 2nd ed. Edinburgh: Churchill Livingston;2004:2;  p.194-195 

5Brody, H. The Top Five List. N Engl J Med. 2010;362(4):283-285

American Healthcare is an American Sickness

George Lundgren, MD penned a commentary in Medscape on April 27, 2017 using the  above title. 

In this commentary he writes about a list composed by Elizabeth Rosenthal, MD in her  book An American Sickness1: 

• More treatment is always better. Default to the most expensive option. • A lifetime of treatment is better than a cure. 

• Amenities and marketing matter more than good care. 

• As technologies age, prices can rise rather than fall. 

• There is no free choice. Patients are stuck. And they’re stuck buying American. • More competitors vying for business doesn’t mean better prices; it can drive  prices up, not down. 

• Economies of scale don’t translate to lower prices. With their market power, big  providers can simply demand more. 

• There is no such thing as a fixed price for a procedure or test. And the uninsured  pay the highest price of all. 

• There are no standards for billing. There’s money to be made in billing for  anything and everything. 

• Prices will rise to whatever the market will bear. 

These are “rules” that are guaranteed to make money, but not to improve outcomes, Dr.  Lundgren writes. 

1Rosenthal E. An American Sickness. How Healthcare Became Big Business and How You Can Take It Back. New York, NY: Penguin Press; 2017

DISABLING AMERICA AND DISTRIBUTING WEALTHPROFITEERING HYPOCRISY

I read with interest a recent holiday message to a health system’s employees about a  young boy who received life saving services from this system through its coordinated  efforts at a state-wide system of communication and best utilization of resources. 

But the health care system in the USA, as we know it has a long way to go to providing  value for it’s out of control and escalating costs. The resources and information are  already here and available to achieve this but they aren’t being utilized; nor are providers  educated in their use or held accountable for using these available proven resources. The  transfer of wealth is a mitigating factor that few are willing to take on, lest it adversely  affect the transfer to them. 

The following is one story of such an example, and sadly I see this type of thing happen  frequently. I’m certain it is of epidemic proportions throughout this system as it is  throughout the country. 

This is the story of a 21-year-old mother of an infant. She had just started a manual labor  type of job in an educational institution and after about two weeks complained of lower  back pain. She was seen by her primary care provider (PCP) who documented no  findings of significant disease or injury, and was referred to me for physical therapy since  I provide a unique and very successful approach using manual therapy and education. 

She presented with her father and her infant child and was in obvious distress, tearful,  and not moving normally. Her examination again was unremarkable for serious  problems and manual therapy provided her with significant relief. Her father remarked  she “was under a lot of stress, and her husband had just left her” in addition to this new  job. She had a history of depression which was currently being treated by her PCP with  medication. 

The patient was given some home corrective maneuvers and asked to return in a week. A  good portion of her therapy session was spent on education, including the futility of  searching for a pain generator; by doing an MRI; and the irrefutable benefits of keeping  active, moving, and doing your normal job – despite pain. 

She returned in a week, moving and walking normally, and reported she was much better,  “just sore”. I found nothing amenable to manual therapy or further corrective maneuvers  or exercise. She could move normally in all directions without any pain. She expressed  concerns about returning to work – this is called Fear Avoidance Behavior and it is  clearly linked to poorer outcomes if not addressed. I advised she not be concerned about  having some pain as a multitude of research studies show this is very unlikely to be  harmful and very highly likely to be helpful if one works through it and builds tolerance.  I suggested it was in her best interest to return to work, and that she should discuss this  with her PCP at the scheduled appointment the next day. 

At her PCP visit the next day it was documented that she was doing much better, and the  therapy had been very helpful. She again expressed Fear Avoidance. She had no  findings of serious problems or any neurological deficits. She was advised to not work,  and was referred to spine surgery for their opinion, and to pain management.  

Four days later she was seen by pain management and this was documented: “She has  been to physical therapy which made things worse…” She had two epidural spinal  injections in two subsequent visits. The first had reduced her pain by 10% according to  the chart. She had also seen spine surgery and a fusion had been recommended. 

She was seen in follow up by her PCP 13 days after the second epidural and the  following was documented: “Depression is not doing well”. It was also documented she  “has not been able to work”. She had been scheduled to have a fusion on December 20. 

I would like to just share some recent staggering statistics: 

🞂 271% increase for epidural steroid injections 1994-2001 

🞂 423% increase for opioids 1997-2004 

🞂 307% increase in MRIs 1994-2004 

🞂 220% increase in spine fusion 1990-2001 

Statistics from: Deyo RA et al. JAFM 22(1);2009 

These authors stated that these increases have not been accompanied by any decline in  the disability rates for low back pain. In fact, they are increasing.  

This 21-year-old will now join this group. 

Dr. Edward L. Scott PT, DPT, OCS 

"We suggest that when treating patients with LBP, medical providers should  pay greater attention to the important role of depression rather than  focusing on the findings or imaging studies". 

Jarvik JG, Hollingworth W, Heatery PJ et al. Three-year Incidence of Low  Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;10(13): 1541- 1548.

Scottisms

• Trochanteric bursitis does not exist for the most part; it is almost always something else causing the lateral hip pain.

• Scapular dyskinesia is a popular diagnosis that is looking for a definition (like fibromyalgia).

• Sciatica or compression of a component of the sciatic nerve is rare (but not in the Lafayette, Indiana area) and has not been shown to be caused by repetitive lifting, bending, or twist.

• Research has not shown that stretching can prevent injuries.

• almost all traditional mechanical factors deemed culpable in NSLBP (Non-Specific LBP) have been debunked in recent years.

• In order to help folks with NSLBP and other musculoskeletal problems one must first de-program them; thus education is paramount to success.

• For a program to be successful, patients must receive the same message based on available evidence from all involved in their care.

• Ruptured or herniated discs, and degenerative changes are common findings even in you asymptomatic people, or as Josh Levin MD says it, “a normal MRI is abnormal”; most imaging is not helpful and may lead to harms for unproven, risky and costly interventions, i.e injections, medications, imaging, surgery.

• Most times a referral for NSLBP should be made only when it is known that therapy has not been helpful and there are no “yellow flags (psychosocial issues)”

• There is only one proven intervention for NSLBP that is effective, safe, and low cost and that is Physical Therapy with manual therapy and/or manipulation, exercises, and education.

• A Physical Therapy evaluation can help delineate the problem. The orthopedic PT has been shown to be equal in outcomes to the fellowship trained orthopedic surgeon but generates lower costs.

• The overall effect on the quality of life of NSLBP is low in the very young and adults that do not seek healthcare for it. Medical management usually exacerbates the problem, not relieve it.

• Most rotator cuff tears - even full thickness - do not need surgical correction; many times care plans are based on imaging findings versus clinical findings, contrary to most expert and evidenced based guidelines.

• Psychosocial issue and depression are infrequently addressed or poorly managed in folks and often leads to medicalizing medical over treatment or treatment that is risky, and not likely to produce a good outcome

Ed Scott PT, DPT, OCS

“Chronic” Back Pain

Most folks are "chronic" because of the vast amount of mixed messaging (outright mistruths) they have been bombarded with. This would take a lot of deprogramming. For instance, some claim stretching will prevent low back pain. Absolute, complete nonsense. There is not a shred of evidence to support this claim. Some claim that Pilates and core strengthening is preventative. Again, with not a shred of evidence. In fact, evidence shows core stabilization/exercises are no more effective than any other exercise the patient may choose to do.

In a nutshell low back pain is normal, and the surest way to make it a chronic problem is to get into the healthcare system, where you are highly likely going to be exposed to myth, and false premises.

I once told a pain management doctor, "would you like to know how to really help this person?" and he said "yes". I suggested he just reassure them to keep moving despite some pain, and for him to quit scheduling follow up appointments. Simple reassurance and being positive for something that is likely going to go away anyhow is powerfully effective. But most providers unfortunately falsely accuse an anatomic pain generator and give them all kinds of false messages and advice. Then when it doesn't work like they said it would - and it won't - the patient has 'back problems' or a chronic problem.

Edward L. Scott PT, DPT, OCS

Sciatica & MRI

Sciatica

need to make a few comments on the diagnosis of “sciatica” (pronounced sigh, at, ick, a).  Sciatica is a rare condition, but that diagnosis is extremely common and made by many, if not most physicians any time a person presents with any pain in leg, even only in the buttock!  Sciatica is a nerve compression of one of the nerve roots exiting the lowermost spine and joining up in the lower buttock to form the sciatic nerve.  True nerve root compression is extremely rare, and I have only seen true sciatic maybe 5 times in 40 years, but I have seen that diagnosis 5 thousand times!  There are many things that can cause pain in the leg, and it does not have to be a pinched nerve.  Folks having a heart attack often have pain in the left shoulder, yet there is no nerve connecting those areas. A simple clinical exam can rule out or rule in true nerve root compression.

MRI

The American College of Physicians and the American College of Pain Management in their research published in 2007 and again in 2011 said that the MRI provides no useful information and is likely to lead to harms (https://doi.org/10.7326/0003-4819-154-3-201102010-00008),  Why would someone order a test like that?  Why would anyone want a test like that?  The simple answer to both these questions – they don’t know this. 

Low Back Pain is Normal

Non-specific low back pain (NSLBP) is as common as the common cold.  It is also just as serious, meaning – it is not.

NSLBP is common back ache that cannot be readily attributed (is not specific) to some other serious cause like a cancer.  Over the last several decades many anatomical structures have been linked to the cause of NSLBP, including disc abnormalities, muscle strains, and muscle spasms, to name a few.  All these anatomical sources or causes of the pain have been debunked.  But not before thousands of unsuspecting patients submitted to costly and harmful interventions promised to “fix” them.

NSLBP is usually a self-limiting problem.  This means it will go away, no matter what is done.  I have been heard saying “if you rub peanut butter on your knee, it will go away” (this will occur in about 2/3 of patients in 6 weeks or less).  The common cold is likewise self-limiting.  And like NSLBP it is highly likely going to occur again, only to go away again.

Nortin Hadler, MD, in his book “The Citizen Patient” describes NSLBP this way: 

Everyone gets backaches – often and repeatedly through life.  Most cope so well that the episodes are not even memorable, despite the fact, that they always present challenges to function.

Sadly, many sufferers seek care, and the NSLBP becomes “medicalized” (turning it into something specific, when it is not) and the clinician offers up remedies based on their specific training, not based on need.  The chiropractor provides manipulation, the physical therapist stretching and abdominal strengthening or core stabilization, and the physician offers pain medication and muscle relaxants.

Unfortunately, those that seek their physicians help are often removed from work, despite overwhelming evidence this is counterproductive. Despite mountains of evidence that remaining active and working, even in pain, is not harmful, and highly likely helpful patients are often advised to avoid doing things that “hurt” until their back heals1.  This advice despite no evidence of a structure needing protected and time to heal?  Patients are commonly advised to avoid lifting and twisting.  They often tell me that turning over in bed causes them significant pain, but no one ever advises them not to go to bed.

So basically, once one enters the healthcare system, they are likely to be offered or subjected to unproven remedies and harmful advice2!  Costly and potentially harmful interventions for something that will go away anyhow. 

Rotator Cuff Injuries

Rotator cuff problems are a wildly popular diagnosis for anyone with shoulder pain.  It is so popular that patients with shoulder pain often believe they have a rotator cuff problem before they have even seen anyone for an examination.

Surgery for rotator cuff tears is much more frequent than it was 20 years ago, and I credit the MRI for that.  Why?  Because many folks, especially men over 50 have rotator cuff tears even though they may have no pain!  I liken it to gray hair – a pretty normal age-related change.

Dr. Gordon Waddell, a spine surgeon from Scotland, calls the MRI “a trap” in reference to low back pain evaluation; Dr. Ned Kuhn, chief of shoulder surgery at Vanderbilt calls it “the tool of the devil” in regard to rotator cuff tears, and I call it “the key to the cash drawer” in regard to rotator cuff tears.

All one must do is present with shoulder pain, and when the MRI is suggested, and you agree to get it, you have stepped into the trap.  Just because the MRI shows a rotator cuff tear does not mean the tear is what is causing the pain, and multiple studies have shown tears to exist in folks that have NO pain.

In one study published in 2017 they did an MRI of both the painful and non-painful shoulder.  They saw worse abnormalities in the rotator cuff in the non-painful shoulder in over 52% of the patients (see reference below). 

Several years ago, I saw a patient who had complained of shoulder pain for over four months.  He had seen 5 different doctors, had injections and tried multiple medications, and had 10 PT and 10 OT visits.  None of this helped him.  I saw him once and resolved his pain and never touched his shoulder – that wasn’t the problem.

On another occasion I saw a 72-year-old man who lifted an empty cardboard box overhead and suffered an onset of shoulder pain and arm weakness.  The MRI showed a rotator cuff tear and after I suggested the patient likely had significant degeneration in the cuff prior to the onset of symptoms the surgeon said this was a “traumatic tear”.  Three weeks after the onset of symptoms he was much better.  But he had the surgery that was recommended – it didn’t improve things.

Below are some excerpts and the studies that they came from, that substantiate what I said above.  (The italicized words are direct quotes from the authors of the studies.)  There are more such studies.

ASYMPTOMATIC ROTATOR CUFF TEARS

Rotator cuff tears are common pathology and are frequently asymptomatic.  Rotator cuff tears demonstrated radiographically during investigation of the shoulder may well not be responsible for the presenting symptoms.  It is important to correlate radiological and clinical findings in the shoulder.

Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJH. Dead men and radiologists don’t lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl. 2006;88:116-121

_________________________

 (the) subject population……..had never sought medical advice for a shoulder problem and all were asymptomatic at the time of the ultrasound evaluation.

Our results indicate that rotator-cuff lesions may be regarded as a natural correlate of ageing, with a statistically significant linear increase after the fifth decade of life.  All the lesions which we found were present without clinical symptoms.  The high incidence of rotator-cuff lesions in the older asymptomatic population, means that in this age group the initial treatment of suspected rotator-cuff lesions should be based on clinical judgement; reliance should not be placed on MR, sonographic or arthrographic imaging of the rotator cuff. 

Milgrom C, Schaffler M, Gilbert S, vanHolsbeck M. Rotator-cuff Changes In Asymptomatic Adults. The Jnl Bone and Joint Surg (Br). 1995;77-B:296-8.

________________________

Shoulder pathology is apparent in both symptomatic and asymptomatic shoulders and clinical symptoms may not match radiological findings. The cost burden of ordering MRI scans is significant, and the relevance of the findings are questionable when investigating shoulder pain.

Gill TK, Shanahan ME, Allison D, Alcorn D, Hills CL.  Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults.  International Journal of Rheumatic Diseases 2014; 17: 863–871 

_________________________

MRI CHANGES MAY NOT BE RESPONSIBLE FOR SHOULDER PAIN

In a study of >40 y/o men and women published in June 2017 the authors did MRIs on the asymptomatic shoulders of workers that reported a work-related injury to the shoulder.  They found worse pathology in the asymptomatic shoulder in over 52% of the patients.  Abnormalities on the MRI were seen in 99% of the symptomatic shoulders and 98% of the asymptomatic shoulders.  They also looked at knee injuries and found similar results.

The authors state:

            Given that MRI signal changes of the shoulder and knee are increasingly prevalent with age regardless of symptomatology, considering newly symptomatic joints with MRI signal changes as injuries related to an acute traumatic event may not be accurate.

Clin Orthop Relat Res. 2017 Jun 9. doi: 10.1007/s11999-017-5401-y. [Epub ahead of print]Liu TC, Leung N, Edwards L, Ring D, Bernacki E, Tonn MD Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes.

BOTTOM LINE

See me to see if your torn rotator cuff that showed up on the MRI is really the problem!  Or better yet, see me before you have the MRI and step into the “trap”! 

PATIENT EDUCATION on Musculoskeletal (MSK) Issues

Patients are often misinformed about musculoskeletal (MSK) issues.  They often latch onto information provided by neighbors or family members.

Sadly, a lot of MSK misinformation is provided to patients from physicians.  They generally receive virtually no training in this area of medicine1.  When they do a residency, they are trained in diagnosis of these disorders by staff physicians, who received no in - school training either.  These staff physicians got their “expertise” as residents also.

Case in point:  How often is a patient placed on their stomach in a physician’s exam room? – almost never!  Even in the exam room of an orthopedic surgeon or so-called “sports medicine” specialist.  Hip extension motion is never assessed. Another case in point:  When a patient presents with pain in the shoulder or arm region, one should “screen” the neck for any involvement.  This is called an “upper quarter screen”.  In my 41 years of practice, I have only seen this done once – by a nurse practitioner.  I have seen dozens of patients diagnosed with shoulder problems, that actually had a neck or upper back problem.

A physician friend of mine once commented “if Ed is to be successful with his patients, he must first debunk myths”.  This is sometimes a tall order because their physician has perhaps provided them misinformation.  This often leads to unnecessary testing and unnecessary prescription of risky medicine.  Then when “incidentalomas” are found, more testing follows, or perhaps even invasive procedures, like biopsies.

In my practice I use anatomical models to explain my diagnosis.  Most often the movement disorder, stiffness, or weakness is readily evident to the patient.  They can feel it or see it.  They are not looking at an x-ray or an MRI or some other picture.  That image could even be from someone else, and they would not know the difference!  But when they feel it on themselves, it is very real.

I do not hesitate to point out the fallacy of the information patients may have been told.  They deserve the truth.  And I rarely provide information that cannot be verified by research.

I have spent nearly all of my 41 years specializing in MSK and have been to many continuing education courses in this area.  I haven’t memorized 5,000 medicines.  I was one of the first just over 1,000 board certified orthopedic therapists in the country in 1992.  So, if you want to know if you really need that surgery recommended on your knee or shoulder, and want to know what is really wrong – see me.  The real beauty is that no harm will be done by unnecessary testing, interventions, or medicines.

1J Bone Joint Surg Am 1998 Oct;80(10):1421-7.  (Note:  This same MSK quiz was administered to 334 staff physicians, residents, and recent graduates 7 years later and 79% of them failed it)

LOW BACK PAIN Myths, False Beliefs, & WRONG Remedies

The right examination or test/xray/MRI can show what is causing back pain

In the absence of a fairly obvious medical problem like a tumor, NO ONE and NO TEST can tell you with reasonable certainty, what is causing your back pain.1

______

Being overweight, lifting heavy objects, awkward postures, standing on hard floors causes back problems

Nearly everyone gets low back pain sometime in their life no matter what size they are, or where they work. And getting it is not caused by lifting, bending or awkward postures, although these may be associated with the onset of pain.2

______

Strong abdominal muscles or core muscles can prevent back pain

If you are alive you are at risk for having back pain. A strong core or strong abdominal muscles will not prevent this occurring.3

______

Prescription medicine is needed for acute or severe back pain

Multiple studies show over the counter pain relievers is just as effective as prescriptions. Physical Therapy that includes manual therapy or manipulation may be helpful, but only a few sessions should be needed.6

______

Rest and back exercises are effective

Resting or avoiding activities that may cause pain is NOT helpful, and may prolong your recovery. Back exercises are very unlikely to be helpful. Flexion exercises were very popular in the 60s and 70s and are no more effective than any other exercise you may choose to do.3,4,5

______

Back problems or chronic back pain “runs in my family”

Chronic back pain or back problems are usually a result of treatment that is ineffective or messaging and instructions based on age-old myths that have no basis in science, research, or simply just a basis in common sense.6

_______

Hurt means Harm and delays recovery/healing

There is no known tissue injury; therefore there is nothing to ‘heal’. Remaining active despite pain has been proven to be helpful.5

_________

Heat or Ice must be applied

All you are trying to do is get pain relief. If “rubbing peanut butter on it” relieves the pain you are accomplishing your goal. Heat or ice application will not “fix” the problem and is not necessary to resolve the back pain.6

_____________

A spine specialist is helpful

Referral to other doctors has not been shown to be helpful or improve outcomes. Physical Therapy that includes manual therapy and/or manipulation has been shown to be effective and improve outcomes.6

1 American College of Physicians and American Pain Society; February 1, 2011. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care

2 Non-specific low back pain Federico Balagué, Anne F Mannion, Ferran Pellisé, Christine Cedraschi Lancet 2012; 379: 482–91

3 Smith et al. BMC Musculoskeletal Disorders 2014, 15:416 Page 2 of 21 http://www.biomedcentral.com/1471-2474/15/416

4 Waddell G. The Back Pain Revolution. 2nd ed. Edinburgh: Churchill Livingston;2004:2; p.194-195

5 Rainville J, Pransky G, Indahl A, Mayer EK. The physician as disability advisor for patients with musculoskeletal complaints. Spine. 2005 Nov 15;30(22):2579-84.

6 Worsening Trends in the Management and Treatment of Back Pain

JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992

Compiled by Edward L Scott PT, DPT, OCS

WORSENING TRENDS IN BACK PAIN MANAGEMENT

(The authors looked at 23,918 patient visits for neck or back pain over a 12 year period)

A couple key points of the study1 found rather large increases in guideline discordant care that has not been shown to improve outcomes

1) referrals to other physicians: (over 100% increase)

2) prescriptions for narcotics (nearly 50% increase)

3) use of advanced imaging such as CT/MRI (nearly 60% increase)

The authors also found a decrease or no change in care concordant with guidelines:

1) decrease in prescriptions of NSAIDs or use of OTC Acetaminophen (nearly 33% decrease)

2) no change in PT referrals

I believe the authors say it well in the final paragraph of their study:

Despite numerous published national guidelines, management

of routine back pain increasingly has relied on advanced

diagnostic imaging, referrals to other physicians, and

use of narcotics, with a concomitant decrease in NSAID or acetaminophen

use and no change in physical therapy referrals.

With health care costs soaring, improvements in back pain management represent an area of potential cost savings

for the health care system while also improving the quality of care

Ed Scott PT, DPT, OCS

1Worsening Trends in Back Pain Management and Treatment

JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992