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

Irecieved an interesting study in my in box this morning. It finds that massage after exercise not only does NOT increase blood flow and, therefore, improve lactic acid removal, it decreases both blood flow and lactic acid removal.

It is reported:

Dr. Tschakovsky said that massage may act by decreasing inflammation, or it may produce a placebo effect. “There is so much inconclusive work out there, that we really don’t understand massage in the context of exercise,” he said.

Interesting study that seems to punch a hole in a long accepted belief on how to minimize pain after exercise.

Jason L. Harris

References

1. Wiltshire V, Poitras V, Pak M, et al. Massage impairs rather than enhances lactic acid removal from muscle after strenuous exercise. Presented at: annual American College of Sports Medicine conference; May 27-30, 2009; Seattle, Wash. Presentation Number: 09-SA-4065-ACSM.

Labels: exercise, massage

Acupuncture (sticking needles at specific points to a certain depth in the skin) is not an effective treatment for chronic low back pain. This may sound surprising as the media has jumped all over a new study that supposedly shows that acupuncture is more effective than "usual care". Unfortunately - as the media usually does - they've misinterpreted the results of the study. In fact the study showed that there is no difference in the effectiveness between "fake" and "real" acupuncture. Meaning, there is no effect of acupuncture.

Steven Novella over at Science-based Medicine does a masterful job of explaining this in detail. Please visit his post on this study to become enlightened by logical and scientifically based thoughts and discussion - as opposed to hype.

Jason L. Harris

Labels: acupuncture, back pain, evidence based medicine

E vidence Base Rehab has recently been named one of the top 51 physical therapy resources on the web. I appreciate the recognition Ownward Healthcare has given this blog. You can find the full list on their website here.

Surprisingly absent from the "Blog" list is Mike Reinold's great blog. Make sure you visit his blog. He has currently begun a series on Patellofemoral Pain Syndrome.

Jason L. Harris

Labels: award, blogs

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