Evidence Based Rehab

Ihave posted several articles on the overuse of imaging in musculoskeletal care (find them here, here, here, and here). Now we have another study from the Archives of Internal Medicine making not only that statement but going as far as speculating that this is related to financial gain, improved patient satisfaction, and potential for more harm that good.

In a news release from Musculoskeletal Report, the study found:

Patients were more likely to undergo imaging tests if their primary care physician worked in large practices and if the doctor was offered patient satisfaction-based financial incentives. Practices with clinical quality-based incentives, however, were less likely to order advanced imaging tests for low back pain patients in the absence of clinical red flags.

Additionally, the article reports on the potential harm of advanced imaging stating:

...advanced imaging of the spine has a low yield of unexpected findings and an “alarmingly high” yield of irrelevant findings.

I'm sure, as physical therapists, we see the fallout from this. More and more patients are presenting in the clinic with simple low back pain (simple meaning no neurologic, systemic, or lytic component - not low in pain) with no treatment beyond narcotics and muscle relaxants and MRI in hand. Now we not only have to try to get them better after 4-6 weeks of prior ineffective treatments, we also have to convince them that all the irrelevant findings (disc bulge, DDD, foraminal stenosis in now way associated with their complaints, etc) are not the problem and will not result in death, or worse, disability.

It seems everyone knows we shouldn't be doing this. Now we just need to convince the gate keepers with their own imaging labs to not perform these unnecessary, revenue generating, insurance companies turn a blind eye to, procedures. I'm sure there will be no difficulty in that.

Jason L. Harris


Hoangmai H. Pham, Bruce E. Landon, James D. Reschovsky, Beny Wu, & Deborah Schrag (2009). Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients Archives of Internal Medicine, 169 (10), 972-981

Labels: evidence based medicine, Imaging, Low back pain

The Insurance Journal released an article discussing how a "surprising" share of work comp case costs come from unanticipated costs or, as they term it, "Adverse Surprise Costs." The study reported on was said to find:

Adverse surprise cases were disproportionately chronic conditions with multiple surgeries. They were also disproportionately back pain cases.

That's no surprise to me, however, and should really not be a surprise to anyone dealing with chronic pain and low back injuries. While back pain is not the only musculoskeletal condition being over-treated with narcotics, expensive imaging, and surgery, it certainly is the most costly of all. In fact, most of my recent posts have centered around this subject (you can find them here, here, and here).

What is surprising is that, despite all this research showing all this imaging, surgery, and narcotic prescription make things worse often, we are still using that recipe to treat most folks with LBP. In fact, those doing it are being the ones rewarded with reimbursement for doing so.

Jason L. Harris

Labels: evidence based medicine, insurance, LBP, Low back pain, over-use

A pair of article from the April 1st issue of Spine remind us of what real reform in health care we need. While President Obama is at least attempting to get the ball rolling with changes in health care, Electronic Medical Records (EMR), expanded coverage, and "investing" in prevention and wellness aren't going to change today's problems at the root of rocketing health care costs.

One piece at the root of these rocketing costs is excessive use of imaging, surgery, and drugs. Low back pain treatment often gets the full brunt of these high cost, low efficacy procedures. Now, the new issue of Spine shines some light on the harm this approach can cause.

In the first article by Timothy Carey, MD - Practice patterns and evidence in chronic low back pain care - it was found that (surprise) there is an overuse of narcotics and imaging and little use of established beneficial treatment of exercise. The figures quoted in the article report fewer than 30% of LBP suffers had seen a physical therapist in the past year and, worse yet, only 3% had gone through a structured rehabilitation program.

The second article by Sham Maghout Juratli, MD - Mortality After Lumbar Fusion Surgery - there was a finding of alarmingly high percentage of deaths after fusion surgery related to Analgesic overdose. The author comments that:

Analgesic-related deaths are responsible for more deaths and more potential life lost among workers who underwent lumbar fusion than any other cause.

So, instead of treating LBP primarly with research-proven exercise prescription there is an overuse of narcotics and surgery that are leading to increased loss of life!

Maybe rewarding those attempting to use what research shows as effective for LBP instead of shelling out billions for imaging, drugs, and surgery might not only lead to lessening costs but decreased mortality.

Labels: evidence based medicine, Fusions, Low back pain, physical therapy

Lancet recently published a systemic review looking at routine imaging for Low Back Pain (LBP) without "red flags" that would suggest serious underlying conditions (eg, myelopathy, cancer, fracture, etc). While the results aren't surprising to the majority of conservative musculoskeletal practitioners, they do need to be publicized to the general public just as much as the silly studies that show "acupuncture" being effective treatment fot LBP. The authors conclude:

Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes," they conclude. "Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition

However, despite studies that show MRI's done for LBP and work related injuries tend to lead to poorer outcomes, and that much of what is foung (DDD, spondylosis, Disc herniations) are "normal" findings, the authors seem pessimistic in MD's changing their behavior.

...there is no compelling reason why more attention should be paid to low back pain than to any other prevalent condition." Other factors include patient expectations about diagnostic testing, reimbursement structures that provide incentives for imaging, and the fear of missing relevant pathology...

Throw in great marketing for spinal surgery, these imaging results are a great stepping stone to push invasive surgery for non-specific low back pain. So, get the word out - stop the excessive imaging and treat LBP initially with what we know has the greatest return for the least potential harm - Physical Therapy, education, and gentle return to activity.

Roger Chou, Rongwei Fu, John A Carrino, Richard A Deyo (2009). Imaging strategies for low-back pain: systematic review and meta-analysis The Lancet, 373 (9662), 463-472 DOI: 10.1016/S0140-6736(09)60172-0

Labels: evidence based medicine, guidelines, Low back pain, MRI

Richard Deyo MD, the keynote speaker at the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) National Conference in October 2008, has again published data indicting the US approach to chronic back pain dramatically increases costs without improved outcomes. Deyo and colleagues reported in the January 2009 issue of the Journal of American Board of Family Practice the following staggering statistics:

• A 629% increase in Medicare expenditures for epidural steroid injections;
• A 423% increase in expenditures for opioids for back pain;
• A 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries;
• A 220% increase in spinal fusion surgery rates.

The incidence of chronic and acute Low Back Pain, as documented by office visits, has not changed during the last 12 years. The application of these technologies is not without consequences Deyo et al noted, ‘Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing.’ Indeed, the reoperation rates for low back pain have increased, not improved. The authors conclude that the ‘Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain.’ They note that these approaches often are applying an acute care model to chronic pain and not acknowledging the current evidence that chronic pain requires a different approach and that there are ‘no magic bullets.’ In a “chronic care model” chronic back pain, like diabetes or asthma, ‘is a condition we can treat but rarely cure.’ Deyo et al suggest the solution that ‘chronic back pain may benefit from sustained commitment from health care providers; involvement of patients as partners in their care; education in self-care strategies; coordination of care; and involvement of community resources to promote exercise, provide social support, and facilitate a return to work.’

Tim Flynn, PT, PhD, president of the AAOMPT states, ‘The manual physical therapist is the health care provider uniquely trained to manage individuals with chronic low back pain. We utilize low risk, state-of-the-art care incorporating exercise, manual physical therapy, patient education and the application of the biopsychosocial model in managing this chronic condition. The Academy is dedicated to the application of current models for chronic pain management.’ The recent AAOMPT conference in Seattle focused on current theories and practice of chronic pain management with international experts on pain management.

Labels: AAOMPT, CPR, Direct access, evidence based medicine, health care, LBP, Low back pain, physical therapist, physical therapy

Degenerative Disc Disease. For many of those that get an unnecessary MRI and get this diagnosis, it's often taken as a death sentence for a back instead of what it is - a normal process related to aging. Although pain can be associated with DDD, it is more often just a radiologic finding. Something that was most likely present before onset of spinal pain and will remain unchanged once the spinal pain recedes.

June's issue of the Journal of Orthopedic & Sports Physical Therapy (JOSPT) includes and excellent commentary on what we know and don't know regarding intervertebral disc degeneration. I would like to summarize some critical points I found in the article.

• Although environmental factors play a role in the incidence and progression of DDD, the strongest predictors are genetically related. It is estimated that 74% of what causes DDD appears related to genetics.
• Smoking and heavy labor have not been supported as etiologic factors in developing DDD. In fact, competitive weight lifters w/o trauma have a lower than expected rate of DDD.
• Primary factor in DDD is reduction of the Intervertebral Disc's (IVD) nutritional capacity.
• "...age-related changes that occur in the composition of the IVD are similar to those observed in articular cartilage and are not necessarily related to pain."
• Vertebral endplate disruptions are being shown to have a strong relationship with DDD.
• Although similar in appearance, there are measurable differences in the diffusion capacity at the vertebral endplate of those IVD's with age-related disc degeneration and symptomatic degnerative discs. This may suggest that aging and degeneration are 2 separate processes.
• "High-Intensity Zones" represented by high intensity T2 signals near the outer margins of the annulus are correlated to pain production with discography (IMO, discography is often painful regardless of pathology) but also commonly found in asymptomatic individuals. This leads to poor specificity and the authors suggest it should not be used in isolation to make clinical decisions.
• The body's attempt to heal annular tears may lead to increasing the area of the disc that is innervated which is further increased by inflammatory byproducts which can lower the threshold needed to trigger pain. The result could be increased sensitivity to otherwise innocuous stimuli. This includes those from just standing and/or walking.
• Even if MRI shows a dramatic disc bulge, this finding is very often not associated with symptoms.
• When nuclear material breaks free and migrates into the vertebral foramen, ipsilateral pain and parasthesia may occur. This results from the chemical response to the nuclear material touching the dorsal root ganglion and not from "pinching" the nerve.

The authors then make some comments on clinical relevance. Here are a few that will lead to a change in the way I treat on Monday:

• Patients with later stage DDD - decreased disc height and hydrostatic nucleus lost - care should be taken during loading progressions, avoiding sustained loading at end range trunk motions.
• Symptoms often occur several hours after trauma to the degenerated disc (DD). Thus, exercise in the gym may go well but in the morning the patient may be too painful to even get out of bed.
• Studies have found favorable outcome in treating DDD with lumbar stabilization exercises.
• It was found that patients with DD who avoided early morning lumbar flexion had significantly less pain and disability then did those who performed lumbar flexibility exercises early in the morning.
• Patients with DD should be encouraged to avoid prolonged flexed compressive forces such as sitting in flexed position.
• Hip ROM limitation can have large effects on loads acting on the lumbar spine.
• The authors make it a point to illustrate the important role the psychological effect that the diagnosis of "degenerative disc disease" has on the patient. they state:
• "...it is important that clinicians carefully communicate with patients to reassure them that DD is a normal aging process; while it certainly can be associated with episodes of pain, only in rare exceptions do these symptoms represent serious disease, and they should not, therefore, prevent one from performing reasonable activities."

It's important to remember the fact DD is related to normal aging. And, thus, it's main treatment should most likely be non-invasive conservative care. And, as I always say, PT's are the experts in this area and well positioned to give the more efficacious care.

Jason L. Harris

Labels: DDD, Degenerative Disc Disease, DRX 9000, evidence based medicine, Low back pain, physical therapy

Anew website has been published providing information and resources on fighting chronic diseases. As we all know, the biggest impact on quality of life and health care costs are the treatment of chronic diseases. The website called "Promising Practices" comments that:

America faces an important crossroads in health care. The Partnership to Fight Chronic Disease, a diverse, national coalition of more than 100 partner organizations, is committed to raising awareness of policies and practices that save lives and reduce health costs through more effective prevention and management of chronic disease. We share common concerns about the incredible burden that chronic diseases place on families, the health care system, and the economy overall.

Though many understand the need for better ways to lower the risks of developing chronic illnesses and reduce the burden of illness on those already affected, they wonder how and where to begin. Innovators in schools, communities, workplaces, and the health care system are proving the value of addressing chronic disease in building a healthier America. Working together, we can develop innovative, common sense solutions to our current health care problems. We encourage you to use these resources to develop and support meaningful changes that will make a difference.

This appears to be a nice resource of patients and providers alike.

Jason L. Harris

Labels: education, Healthcare, Low back pain

More surgery, more drugs, and more injections are not what the doctor ordered.

Tallahassee, Florida, May 20, 2008 – When it comes to chronic back pain management patients should know that “less is more.” The American Pain Society at their annual meeting unveiled a current review on invasive procedures for the treatment of chronic low back. The scientific review concluded that most invasive interventions, including spinal joint injections, radiofrequency denervation, intradiscal electrothermal therapy demonstrated no evidence of effectiveness. Furthermore, surgical procedures for chronic low back pain demonstrated only small improvement in pain and disability but were accompanied by considerable risk.

"The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou."

“The American Pain Society panel has acknowledged the central role of an active physical therapy program in managing low back pain patients,” noted Timothy W. Flynn PT, PhD, President of the American Academy of Orthopaedic Manual Physical Therapists. “The key in chronic low back pain is avoiding too much medicine. There is no magic bullet but a combination of hands on care and an active exercise approach is the best solution.”

Labels: AAOMPT, evidence based medicine, Healthcare, LBP, Low back pain, physical therapy, public relations

Isn't the internet great? Now you can receive consultations for sacroiliac pain over the phone. While I agree general advice can be delivered via telecommunications (especially with an established patient) it seems to be a stretch to do the same for low back/SI pain. As PT's our greatest tools are our hands and our minds. Seems this patient care approach is eliminating 1/2 of those tools. What do you think?

Labels: Healthcare, LBP, Low back pain

I wanted to share a nice resource I recently found on the internet. It is an online publication of the book "Back Care Boot Camp" which covers many educational aspects for patients on low back pain. The online (free) version appears to leave nothing out in terms of what the book offers to the patient. You can also purchase an ebook version or have a patient purchase an individual section to print. Each section costs only $1.00 and the whole ebook in $4.95.

This appears to be a very nice resource to supplement you patient education and re-emphasize important topics covered in a patients clinic visit. Check it out and let me know what you think.

Jason L. Harris

Labels: Direct access, education, LBP, Low back pain

The APTA recently released an article on the benefits of seeing a Physical Therapist (PT) for back pain. They point out that despite a recent article in the Journal of the American Medical Association (JAMA) that even with rising costs associated with back pain there has been no improvements in care, PT's have an excellent track record with the public, and more importantly, in the literature showing our effectiveness in treating back pain with out surgery or drugs.

Consumers need to know that physical therapist management is a low-cost, high-value alternative to drugs and surgery to deal with musculoskeletal pain," said APTA President R Scott Ward, PT, PhD. "The judicious use of appropriate physical therapist treatment based on best evidence can improve the function of people who struggle with back and neck conditions." Ward added, "Because patients with chronic, disabling low back pain account for a disproportionate share of health care expenditures and workers' compensation costs, the potential cost savings of an early, effective intervention to prevent individuals from progressing to chronic disability may be considerable.

Here is the link to the press release.

Labels: AMA, APTA, evidence based medicine, LBP, Low back pain, manipulation, outcomes, physical therapist, physical therapy

Drugs, Surgery, or Physical Therapists

A great post over at Evidence in motion on good news coverage on the benefits of physical therapy. I usually don't like to make post on other posts, but this seems to scream to be an exception. Please click the link above to read.

Here is the link to the video on back pain and physical therapy.

Labels: Direct access, evidence based medicine, LBP, Low back pain, physical therapy

Here is a follow up to the Clinical Prediction Rule for Lumbar Manipulation video I posted on a while back. Again, this video is presented by Physical Therapy Students hoping to educate the rest of us on the best treatment choices for our LBP patients. Enjoy!

Labels: clinical prediction rules, CPR, EBM, LBP, Low back pain, stabilization

Ihave been meaning to blog on the results of a Lancet article finding neither spinal manipulation or NSAIDs are effective on low back pain. However, Eric from NPAThinktank beat me to it with a post on Evidence in Motion's blog. It is very well done and thought out.

The key point we must all understand, is that the population tested was a heterogeneous group of low back pain sufferers. Despite the mounting evidence, no sub-grouping of patient's was done. Predictably, then, to significant results were found. I don't care how many low back pain studies are done, if no treatment based classification is used, you will not find significant results.

Eric quotes Dr. K. Shepard using a great analogy for this. I post it here for your convenience:

A study that randomly assigns patients with low back pain to various conservative treatment protocols will produce the same results as a study that randomly assigns patients with abdominal pain to undergo appendectomy, cholecystectomy, or exploratory laparotomy. Neither study makes any sense.

Our hope in the rehab world is that the referral sources also have the great evidence of treatment based classification and the dramatic effects of lumbar manipulation on the right sub group of low back pain patients. Please read Eric's great post.

Labels: clinical prediction rules, EBM, Evidence, Low back pain, manipulation, physical therapy

Students from the University of Regis attempt to spread the knowledge regarding the Clinical Prediction Rule for SI manipulation. Fairly corny, but it gets the point across. Appears aimed at the clinician more than a prospective patient.

Are you manipulating your patients that fit the CPR? Change is difficult, but must be made to continue evolving as clinicians and providing the best care known (friggin state of Iowa and their collusion with "Palmerville")

Labels: clinical prediction rules, EBM, Low back pain, manipulation, Mobilization, physical therapy

The public has been exposed to the media over hyping (and misrepresenting) a study that finds acupuncture to be more beneficial than "western medicine". I was first exposed to this by an article on MSNBC entitled "Acupuncture - real or fake - best for back pain." Emphasis added.

Let's take a closer look. Here is a link to the full text. Luckily, this study, and the reporting of it, seems to be recieving great analysis and coverage. This includes Orac over at Respectful Insolence; Dr. Steven Novella's NeuroLogica Blog; and Dr. Ben Goldacre at Bad Science. These two are more intellingent than me, and, most importantly, are able to express themselves better. Please take the time to read their posts. Especially Orac's.

I would just like to highlight a few problems with this study. Understand, though, most studies have flaws and that does not mean they are worthless. However, these flaws must be known because they greatly effect how a study can be applied to you/me/us.

1. This study, as designed, is wholly unreproducible. Why? The "conventional treatment" group was not controlled (well). Some received all, some, one, etc of the "allowable" conventional treatments. Maybe acupuncture is a cure all, maybe not. However, another study using the same methods, cannot be done because the conventional treatment group can not be reproduced.

2. The inclusion/exclusion criteria eliminated the vast majority of patients we see (and for those reading, what you have). Therefore, cannot be applied to much of the LBP population. Orac argues this point well:

One point that leaps right off the page is that the patient population studied had had chronic low back pain for at least 6 months and, based on that duration and the patients' willingness to try acupuncture, we can reasonably infer that their pain probably wasn't responding particularly well to conventional therapy. This makes it unsurprising that the reported response rate in the standard therapy group was so low, given that it was just getting more of the same treatment.

3. There was no blinding. All the participants knew what they were receiving, and, presumably, the same practicioner was providing the "real" and "sham" acupuncture. Although is both the real and sham acupuncture did just as well...does that mean that all acupuncture is sham or that any needling is real acupuncture? Hmm..... In my opinion this opens the door to rater bias and a very large placebo effect (hmm, the 'I'm receiving a "new" treatment' group does better than the 'I'm receiving the same crap that hasn't seemed to work in the past' group).

What to make of this study then? Those with chronic LBP not linked to any known causes (sciatica, DDD, OA, Surgery, etc) that "conventional" treatment has not worked, improved with "shamish" acupuncture compared to the same old crap. Not quite the same as "Best for back pain".

Labels: acupuncture, alternative medicine, EBM, Low back pain, physical therapy

Found a brief PR article on lumbar stabilization by Physical Therapists. It is from ADVANCE magazine and the article can be found here. It appears directed at nurse practitioners, which is an important audience for us as more and more of family practice is being handled by "second tier" providers.

Maybe something that could be added to you "packet" of general information one could provide to your referral base.

Labels: Direct access, education, Low back pain, physical therapy, physicians

After many question from my patients and the general public regarding "alternative" treatments (e.g. magnets, craniosacral, dietary supplements, etc) I decided to sit down and write up an educational handout to summarize how to approach evaluating treatment options. This includes treatments in so called "Alternative Medicine" and main-stream medicine alike.

I am very concerned that many alternative treatments are blatant attempts to take advantage of persons in desperate situations. Such as end-stage cancer and progressive disease processes like arthritis.

Below are some ideas on how to approach decisions about "new" therapies to allow you to maximize your potential gains and to protect your money from those offering up only a big handful of woo.

---

EVALUATING INTERNET MEDICAL ADVICE

Jason Harris, PT, DPT

Our modern internet has opened the door to a vast arena of medical advice and information. With this information, it is important to critically evaluate the information and the author’s credibility. How does one pick between credible and worthless? It can be hard, but I will outline a few rules for judging the value of the information you are reading.

I suggest you look for "Red Flags" while researching medical information on the internet. In medicine "Red Flags" are signs and/or symptoms that warrant immediate attention as they indicate a potential life threatening situation. I will use the term to indicate immediate problems with information that is being evaluated.

"RED FLAGS":

1. Any site that use the terms "alternative", "holistic", "integrative", "natural", and/or "miraculous" (Barrett). The vast majority of websites using these terms should replace them with “unproven” and/or “ineffective”. They also tend to push Herbs, vitamins and supplements. Do not trust a salesman to tell you the whole and complete truth. Their job is to sell you the product.

2. Claim large effect on symptoms with out side-effects. Causing a large change in body function (or dysfunction) has a cascading effect that leads to known side-effects and occasionally adverse reactions. No side effect most often indicates such low doses as to have no real effect.

3. Claim that a treatment can cure multiple problems/pathologies. Nothing can, or ever will, cure your shoulder pain and skin melanoma.

4. Claim that everyone will experience the same positive results. Humans are not all the same. Disease processes are complex and include multiple organ systems to varying degrees. Due to this, you cannot expect all to respond the same way or to the same degree. This is why well run clinical trials are essential. Which brings us to the next point…

5. The use of testimonials as sole proof that treatment works. A positive experience one person has cannot be generalized to anyone else. This is a complex topic as we rely on recommendations and advice from our neighbors to function efficiently in society and these salesmen attempt to take advantage of this.

6. Person is touted as a “Guru” with many impressive sounding “credentials”. Often claims are made that your problems can only be cured by the seller. Often it is because of some procedure or test named after them that only they can do. In the end, only they can do it because there has been no published research to support or refute it’s ability to do what it is purported to do. Also watch for the use of “Dr.” when referring to this guru and/or unusual credentials (e.g. not common known credentials such as MD, DO, PhD). The use of the doctor title is an attempt to make the person appear more authoritative then they are.

7. Must buy to see results. Any reputable treatment/product should have peer-reviewed published literature that shows it can do what it claims. You should never have to first buy something to know or experience how it works.

Medical information from the internet must be reviewed wisely and used as a supplement to the advice a trusted healthcare professional has given you. When in doubt, bring the information you have found to your MD, DO, or PT and discuss it with them. These “red flags” are a good start to filtering out the majority of bad from the good.

Works Cited

Barrett, M.D., Stephen. " How to Spot a "Quacky" Web Site." 06 September 2006. Quackwatch. 7 July 2007 .

Labels: alternative medicine, Chiropractic, education, Fraud, Low back pain, physical therapy

A new study from Spine concludes that there are muscle changes that, they conclude, are common in those with true low back pain. Here is the abstract:

Study Design. Prospective longitudinal study.

Objective. To investigate, using magnetic resonance imaging (MRI), the influence of bed rest on the lumbopelvic musculature.

Summary of Background Data. Reduced gravitational loading and inactivity (bed rest) are known to result in significant change in musculoskeletal function, although little is known about its effects on specific muscles of the lumbopelvic region.

Methods. Ten healthy male subjects underwent 8 weeks of bed rest with 6 months of follow-up. MRI of the lumbopelvic region was conducted at regular time-points during and after bed rest. Using uniplanar images at L4, cross-sectional areas (CSAs) of the multifidus, lumbar erector spinae, quadratus lumborum, psoas, anterolateral abdominal, and rectus abdominis muscles were measured.

Results. Multifidus CSA decreased by day 14 of bed rest (F = 7.4, P = 0.04). The lumbar erector spinae and quadratus lumborum CSA showed no statistically significant difference to baseline across the time of bed rest (P > 0.05). The anterolateral abdominal, rectus abdominis, and psoas CSA all increased over this time. Psoas CSA increased by day 14 (F = 6.9, P = 0.047) and remained so until day 56, whereas the anterolateral abdominal CSA (F = 29.4, P = 0.003) and rectus abdominis CSA (F = 8.9, P = 0.03) were not statistically larger than baseline until day 56. On reambulation after completion of the bed rest phase, multifidus, anterolateral abdominal, and rectus abdominis CSA returned to baseline levels (P > 0.05) by day 4 of follow-up, whereas psoas CSA returned to baseline level after day 28 of the follow-up period.

Conclusions. Bed rest resulted in selective atrophy of the multifidus muscle. An increased CSA of the trunk flexor musculature (increases in psoas, anterolateral abdominal, and rectus abdominis muscles) may reflect muscle shortening or possible overactivity during bed rest. Some of the changes resemble those seen in low back pain and may in part explain the negative effects of bed rest seen in low back pain sufferers.

This adds to the growing mountain of evidence against bed rest for LBP. One would hope that the current first line practitioners that LBP patients encounter (GP's and, sadly, PA's and NP's) know this; but, as Ellen Degeneres showed us even "stars" are given advice contradictory to the mounting evidence. What's worse is her large audience may also believe that bed rest is the best treatment for their low back pain.

Educate, educate, educate. Tell everyone you know about the harm of bed rest!

Labels: bed rest, EBM, Low back pain, treatment

In this Wall Street Journal article, the issue of excessive imaging and surgeries for back pain is discussed. As PT's we have all seen the patients that have had x-rays and MRI's for simple non-traumatic back pain and wondered 'Why were these done'. The article lists common missteps doctors make when treating back pain:

• Over-prescribe epidural steroids.
• Order excessive imaging
• Perform invasive surgery too soon.
• Fail to educate patients about surgery and alternatives to surgery.
• Fail to assess mental health.

Why do doctors do this? Physicians are very smart and good at what they do; but, they are human just like us. Fear of litigation, pressure to please the patient, and just not knowing a better way are all plausible answers. The problem is, there are studies that show unneeded imaging can lead to diminished outcomes, and lumbar fusion surgery offers negligible benefits at best for the majority of the back pain population for the risks involved.

The program is spearheaded by the National Committee for Quality Assurance and strives to reward physicians that follow the plan and to educate the public about their options besides surgery. They produced a list of 16 guidelines for MD's to follow with a few listed below.

RIGHT CARE FOR ACHING BACKS

A new program is urging doctors to follow 16 guidelines including:

• Help patients quit smoking
Smokers with back pain have more severe symptoms that last longer and have poorer outcomes after spinal surgery.

• Encourage patients to maintain normal activities and avoid bed rest
Bed rest can lead to problems such as joint stiffness, muscle wasting, loss of bonemineral density and pressure sores.

• Use X-rays and CT scans only when appropriate
Unnecessary for first six weeks after onset of pain unless there is indication of a more serious disorder.

• Use epidural steroid injections only when necessary
Not recommended unless symptoms include radiating pain (sciatica, herniated disc).

• Hold off on surgery
Not recommended in first six weeks of pain onset; half of patients with radiating low back pain recover spontaneously.

Conservative care and education should lead to improved outcomes and lower costs in treating back pain in this country.

Labels: Low back pain, over-use, physical therapy, surgery