Lumbar Imaging: Epidemiology reporting with results changes management

[Michael McMurray]

Have a read over the weekend and post your thoughts.

Cheers

Eric

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[Nick Law]

The most immediate thing that comes to mind in light of this study is: do is it really require a printed epidemiologic statement on the MRI report to help the MD understand the findings in their proper context? I mean, does anyone else think that the mere idea of having to perform this study draws attention to the apparently large deficit in primary care’s understanding of common, non-concerning findings on MRI reports? And the fact that there was a change in narcotic prescription based on the printed statement further confirms that they were impacted by the statement, further giving evidence of their prior ignorance.

This is such a basic, well known, easy to understand issue, that the necessity of a printed statement on the MRI report seems utterly absurd. The burden of persistent LBP is so large and expansive, that to be unaware of the basic issues surrounding it, proper education and management, seems inexcusable.

I certainly had more of an emotional response to this article than to most. Anyone else feel the same? Different?

[ABengtsson]

Thanks for posting this Eric!

Nick – I think you’re making a great point in your first paragraph and I’m right there with you. I’ve already had a few pts who had all kinds of procedures, but didn’t know anything about what was going on in their back, besides their disc being bulged/blown out/blown up/torn/out of place/ripped and whatever else they say.
Just last week I evaluated 2 pts who had back sx.
One of them had her sx a month ago and hasn’t moved since, except for going to the bathroom. She was so afraid that she just stayed in bed for 4 weeks, trying not to move a muscle. DTRs and dermatomes were all normal, but she could barely walk without her walker (or with for that matter) and her myotome testing was a disaster. Her original injury (HNP) was 2 years ago and she said she hasn’t moved much since, because she was afraid moving would make it worse. Obviously, there’s no telling how bad her syx were, but according to her she had no loss/decrease of sensation and no weakness in her legs after the injury; just pain.
The other had his sx last summer after having received 6 epidurals within 2-3 months, of which only the first one helped somewhat. He said he didn’t have any changes in sensation, or apparent strength deficits, just pain in his low back and down his leg. After his sx he felt better for a 1-2 months (perhaps bc he didn’t perform any of the activities that aggravated his syx before the sx during that time frame), but has been back to square one since then.
Neither pt had been to PT for these issues before their sx, or epidurals. I’ve had a handful of pts like this since September and I’ve been wondering how many of them actually needed that sx. What they all had in common was a focus on the horrible things that the images showed and some very fear inducing language regarding their condition.
All in all incredibly frustrating, not only regarding the individual pts, but also overall effect on healthcare costs etc.
Just sent this article to all my MD/med school friends.

[Laura Thornton]

This discussion board is highly entertaining. Once again, more substantial evidence of the downfalls of MRI imaging for this subset of patients and although it’s been supported in the guidelines of the American College of Physicians and American College of Radiology since 2012, why is this still a prevalent issue?

I don’t know about you all but I have never seen epidemiology reports on MRI imaging.

What is happening here? There is no explanation on why some MRI reports had the epidemiology data and some did not. Including this data had a clear, significant correlation with higher rates of narcotics use, re-imaging, injections, etc. Was this the radiologist’s decision to include the data in the MRI reports? Seems like it would be a pretty easy thing to place on every report regardless, since the printed statement had clearly profound effects on treatment in this retrospective study. WHY this effects treatment is another issue.

I say as clinicians in every field (medicine, physical therapy, nursing, etc), let’s all get on the same page here to prevent catastrophizing and help this subset of patients get better.

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[Laura Thornton]

I recommend reading the section in the article I attached:

“WHAT FORCES PROMOTE THE OVER– USE OF IMAGING
IN PATIENTS WITH LOW BACK PAIN?”

[sewhitta]

Yeah it’s frustrating for sure. I feel the big issue is that a large portion of clinicians have no incentive, or perhaps desire, to search for this research or to change their common practice. Additionally, there is no one that is questioning their practice and holding them accountable for their decisions. It’s very easy for a clinician to fall into a habit of doing the same thing, over and over again. The fact is, these physicians have little to offer these patient’s, and they want to be responsible for making the patient better. If the clinician isn’t trying to find a better and more reasonable treatment approach, they’re not going to find it. They will continue to do things the same way. This is not just physicians, its physical therapists as well. Clearly the evidence needs to be thrown in their face to put it into practice. So the question is, how can we change the practice? The way I see it, there are two options: 1) the media, and 2) direct access for physical therapy. The public needs to make the decisions. If we can get the message out to the public, and they demand alternative treatments to medications and surgeries, then clinicians will likely change their decision making process. If the public knows that disc degeneration and bulges are normal, then hopefully, they will question their doctors and seek other treatments. Too often patients question nothing and go along with whatever the doctor says because, well, they’re the doctor and they know everything. This is why direct access is so important. For this patient population, we are their best option and it should be up to us to decide whether or not they need an MRI or medication for their condition. But the problem is many patients feel the doctors’ opinion is superior to all others and the media feeds into this as well. Everyone feels the “doctor” will make the best decision and prescribe the best treatment. People believe everything they see on television and, unfortunately, everything on television is garbage. I don’t see why physical therapists couldn’t create a commercial highlighting these common statistics and emphasizing our treatment approach. I see commercials by physician groups all the time on how effective spinal surgeries are. Why shouldn’t we do this and what’s holding us back, besides the cost?

[Nick Law]

Laura – thanks for taking the time to pull and post that clinical guideline. I read the section you mentioned and thought it was very beneficial and continues to highlight several of the issues at hand. I highly recommend even just that section to the rest.

Sean – I think educating the public is certainly a good option and one that we should be aiming at, however I am uncertain that it alone will be enough to make the appropriate changes. The patient-held belief that imaging is necessary to truly determine the source of pathology in their back is a deeply rooted, strongly held faith, and I am not sure that we as PT’s alone have the kind of public respect and authoritative voice, as of yet, to change that. This is especially difficult if what we are saying goes AGAINST the grain of what the patients MD is telling them.

I think this a ridiculous issue that is causing a lot of people harm and a lot of health care dollars lost, but I don’t think the solution is necessarily an easy one.

Although it should be completely unnecessary for the physician, I am not sure why an epidemiologic statement would not be placed on every single MRI report for routine LBP.

[sewhitta]

Nick – I completely agree, we don’t have the public respect. That’s why I feel it’s absolutely necessary to have more of a voice to the public. I feel I’m often going against the grain of what MD’s are telling patient’s all the time. That’s what’s so frustrating. Treatment would be so much easier if the MD, instead of me, told the patient these MRI findings are normal. However, it’s not against the grain of all MD’s. This article was published by MD’s. It’s only against the grain of MD’s that aren’t aware of the current literature, or who choose not to utilize it.

So, question for everyone: how do we establish this voice and what else could we do to facilitate a change?

[Michael McMurray]

I agree Laura – Highly entertaining (mainly Nick) – love the introspective, thoughts, patient applicability, and need to make some practice changing adjustments.

We all have biases, practice patterns that we fall in to – so do many MDs (even the good ones).

Remember this JAMA conclusion :”It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice.”

The Aussies have been doing a much better job of educating the public regarding some of these practicing changing conclusions in the evidence through the National Public Health resources. Public service campaigns to distribute this/and similar information to the general public.

Maybe we as US Physios need to continue to do a better job on a national scale educating and distributing information that eventually decreases the expenditure for the most expensive health care consumers – chronic non specific low back pain with high fear/disability.

Thanks everyone for your thoughts/efforts – keep it up

Cheers – Happy pending Snowpocalypse

[omikutin]

I’ve thought a lot about this article. Yes- we know that MRI findings do not correlate to symptoms. I educate patients about MRI correlations and symptoms, that barely gets through. Some patients come back with MRI’s and it’s as if they’re healed (several hundred dollars later). Has anyone had patients like that? It doesn’t always happen to me, but patients will want to do what they want to do.

I know reaching out to MDs can be difficult because most of them do not want to change their habitual practice. I do appreciate that this article was written by an MD and I think it’s great to share this with different medical practices. We did a spinal/posture educational class at a medical office and it was great. We also participated in an x-team fitness class and people asked us PT questions after. I’m learning that one of the best ways to promote change is to educate, finding the time is rough! As for social media, I have seen some PT commercials via youtube. I’ve used FB to educate on what’s out there for PT and I’ve had several people email me questions.

Sean- I agree with you we need a voice and so far we have social media. It’s a little intimidating teaching at a fitness facility when others have 10+ years of experience and I just graduated. Building confidence is one thing, the second thing is getting out there.

Laura- That’s a great article! People constantly want to know what’s going on. Diagnosis is important, but also impairments help guide our treatment. I try to connect some of the dots for my patients and show how that relates to their low back pain. IE: “when you walk your hip doesn’t extend well and therefore you can see how that increased stress on your low back when walking.” Having a skeletal model is helpful.

Thanks for all your thoughts, they’re very helpful!

[Michael McMurray]

CDC Says Nondrug Approaches ‘Preferred’ to Treat Chronic Pain; APTA Adds its Support

The US Centers for Disease Control and Prevention’s (CDC’s) draft clinical guidelines on the use of opioids for chronic pain make it clear: nondrug approaches such as physical therapy are the “preferred” treatment path for chronic pain.

APTA couldn’t agree more.

This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—”enough for every adult in the United States to have a bottle of pills,” according to the CDC.

The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which nondrug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.

Its first recommendation: “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”

“Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain,” the draft states. “In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months.”

In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy “have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain.”

APTA’s comments also note that referral to exercised-based interventions “is essential prior to the initiation of opioid-based therapy,” and that exercise interventions “have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions.”

The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from nondrug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.

APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches “have been challenged by reimbursement policies.” APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to nondrug approaches to chronic pain.

The CDC guidelines—and APTA’s comments—come at a time when the fight against opioid abuse and heroin use has gained attention at a national level. The issue was a part of President Barack Obama’s final State of the Union address on January 12, and the epidemic is the subject of a White House initiative that includes APTA and other health care and corporate partners. At the state level, West Virginia—one of the states hardest hit by the opioid abuse problem—has announced the formation of a new House committee on substance abuse. That committee includes Rep Mick Bates, PT.

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