It is time to stop causing harm with inappropriate imaging for low back pain

The Clinical Utility of Repeating Magnetic Resonance Imaging (MRI) Scans Within 12 Months in the Management of Lumbosacral Degenerative Disc Disease

PURPOSE

Magnetic resonance imaging (MRI) is the gold standard investigation for lumbosacral degenerative disc disease. However, there is controversy regarding the clinical value of repeating an MRI scan within 12 months when a patient presents with recurring or changing symptoms. This study measures rates of radiological change in a real-world cohort to guide clinicians when deciding to repeat a scan.

METHODS

All patients over a 10-year window in one general hospital who underwent two lumbosacral MRI scans for degenerative disc disease within 12 months of each other were included in the study. All MRI reports were manually reviewed. The level of main vertebral pathology was recorded, along with the location of a disc prolapse. Time intervals between the two scans were calculated, and these were collated into 30-day intervals for analysis. The repeat scans were categorized into three groups: no change, radiological improvement, and radiological deterioration. Patients who had clinically significant deterioration in the form of cauda equina compression on MRI scans were recorded.

FINDINGS

Four hundred and eighty-one patients were included for analysis. Three hundred and ninety (81%) showed no change in MRI findings, 18 (3.7%) had improvements in their repeat scans, and 73 (15.3%) demonstrated deterioration in their repeat scans. Of the 73 patients with radiological deterioration, three patients (0.62% of the total) required urgent surgical intervention for cauda equina syndrome (CES).

CONCLUSIONS

Though there is no alternative to detailed clinical assessment in determining whether a repeat MRI scan is indicated, the findings demonstrate that repeating MRI within 12 months for patients with lumbosacral degenerative disc disease has a low chance of altering the management plan. Over the 10-year period, only three patients required an urgent change to their clinical management. We believe this data can help guide clinical decision-making when considering a repeat scan.

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

BACKGROUND

Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette.

METHODS

Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes.

RESULTS

In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP.

CONCLUSIONS

The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

The Correlation of Frequency of Work-Related Disorders with Type of Work among Polish Employees

Musculoskeletal disorders have a significant negative impact on the quality of life of the population. These conditions, as well as other work-related disorders, generate costs associated with treatment and work absence, which makes it a growing problem in industrialized countries. Available data from studies on individual populations of workers indicate a higher incidence of certain symptoms in these groups. Due to the lack of studies on the general population, we aimed to perform the preliminary study evaluating the occurrence of pain and work-related conditions depending on the type of occupational work among Polish employees to identify further possible areas for research. Data was collected using an electronic self-administered questionnaire, which was distributed in groups bringing together various professionals. The data obtained from 379 participants have been analyzed and divided according to performed work into sedentary, forced posture, standing, physical and requiring physical activity. Our study reveals a correlation between the frequency of work-related disorders and type of work performed in the Polish population. A significant correlation between the type of occupational work and prevalence of ankle, knee and shoulder pain, as well as heavy legs or upper limb paresthesia was found. According to our findings, female employees may be more vulnerable to lower limb symptoms. A place of residence also seems to affect the prevalence of upper back pain and heavy legs. The analysis also showed a correlation between the occurrence of hip, knee and ankle pain and the level of education of the participants. Surprisingly, lower extremity paresthesia was significantly more common among participants undertaking additional physical activity, compared to non-physically active respondents.

A Call for Interdisciplinary Collaboration to Promote Musculoskeletal Health: The Creation of the International Musculoskeletal Mental and Social Health Consortium (I-MESH)

Despite increasing recognition of psychosocial factors in musculoskeletal conditions, its impact on reducing the global toll of musculoskeletal symptoms has been only incremental. It is time to bring together clinicians and researchers with heterogeneous backgrounds, unified by a commitment to reduce the global impact of musculoskeletal illness by addressing mental and social health factors. In 2020, we initiated the International Musculoskeletal Mental and Social Health Consortium. Our current key priority areas are: (1) Develop best practices for uniform terminology, (2) Understand barriers to mental and social health care for musculoskeletal conditions, (3) Develop clinical and research resources. The purpose of this paper is to render a call to interdisciplinary collaboration on the psychological aspects of musculoskeletal health. We believe this international interdisciplinary collaboration is pivotal to the advancement of the biopsychosocial model of musculoskeletal care and has the potential to improve the health of individuals with musculoskeletal conditions globally.

Defensive medicine: A symptom of uncertainty?

Defensive medicine is a well-documented phenomenon and refers to the practice of over-cautious management of patients, leading to excessive clinical activity such as over-investigation, unnecessary appointments and additional interventions. Adopting this approach is not in the best interest of patients and can lead to clinical reasoning being replaced by lists, guidelines and algorithms which do not consider the complexity of a patients presentation or the reasoning inherent in good clinical judgement. The drivers of defensive medicine are varied and include a high level of uncertainty alongside other factors including clinical experience with past cases, system pressures and patient expectations. This paper explores these drivers and considers strategies on how best to avoid a defensive medicine approach. It reinforces the need to adopt a patient centred focus and use sound clinical reasoning to support the management of patients.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

Background

Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL).

Methods

This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging.

Results

Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation.

Conclusions

Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01751-6.

Only one fifth of young Australian adults have beliefs about medical imaging for low back pain that align with current evidence: A cross-sectional study

BACKGROUND

Patients' perceptions/expectations may be a factor behind medical imaging referral rates. Few studies have investigated the beliefs that might drive expectations of medical imaging.

OBJECTIVES

This study examined whether beliefs of young Australian adults with and without impactful low back pain (LBP) concerning medical scans for LBP align with current evidence. It also investigated if these beliefs were associated with clinical factors (history of impactful LBP, history of previous medical scans, LBP-related disability and the presence of leg pain) or sociodemographic factors (sex, education, income).

DESIGN

Cross-sectional observational study.

METHODS

78 participants from the Raine Study with a history of impactful LBP and 85 participants with no history of impactful LBP completed a study-specific questionnaire with five statements concerning beliefs about medical imaging for LBP. All statements were not aligned with current evidence about the use of medical imaging in LBP management.

RESULTS

Only 15-21% (n = 24-34) of the participants held beliefs that were aligned with current evidence. Participants with a university education had slightly more aligned beliefs compared to those whose highest education was completing secondary school. There was no difference in the beliefs of participants based on their history of impactful LBP, or other clinical or sociodemographic factors.

CONCLUSION

As beliefs are likely to drive care-seeking behavior, it is notable that most participants' views about the role of medical imaging for LBP were not aligned with current evidence. Therefore, this suggests a need for community education, especially for those with lower education.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Dutch multidisciplinary guideline on Achilles tendinopathy

Objective

To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients.

Design

Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase.

Data sources

Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference.

Study eligibility criteria

Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module.

Data extraction and synthesis

To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations.

Primary outcome measure

The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions.

Results

Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy.

Summary/conclusion

Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Understanding Shoulder Pain: A Qualitative Evidence Synthesis Exploring the Patient Experience

OBJECTIVE

The objective of this study was to review and synthesize qualitative research studies exploring the experiences of individuals living with shoulder pain to enhance understanding of the experiences of these individuals as well as facilitate health care developments.

METHODS

A meta-ethnographic approach was adopted to review and synthesize eligible published qualitative research studies. The findings from each included study were translated into one another using the Noblit and Hares 7-stage process. A systematic search of 11 electronic databases was conducted in March 2020. Methodological quality was assessed using the Critical Appraisal Skills Programme appraisal tool.

RESULTS

Nineteen studies were included in the meta-synthesis. Included articles explored the lived experiences as well as treatment-related experiences of participants. All of the included articles were deemed to be of high methodological quality. Three themes were identified: (1) negative emotional, social, and activity impact ("It has been a big upheaval"); (2) developing an understanding ("Why is it hurting so much?"); and (3) exercise ("Am I going to go through a lot of pain in moving it…?"). Across the included studies, the severe emotional and physical impact of shoulder pain was a core finding. Many people sought a "permanent" solution involving surgery. Openness to other treatment options was influenced by factors including understanding of pain, prior experiences, and treatment expectations.

CONCLUSION

These findings deepen our understanding of the impact of shoulder pain on peoples' lives and provide novel insight into the experience of treatment. Enhanced awareness of people's experiences of shoulder pain and treatment is crucial for clinicians when planning and implementing evidence-based recommendation.

IMPACT

To the knowledge of the authors, this is the first qualitative evidence synthesis to explore the treatment-related experiences of individuals with shoulder pain. Shoulder surgery was considered by many as the only means to achieve a more permeant resolution of symptoms.

LAY SUMMARY

Shoulder pain causes emotional and physical turmoil that can permeate every facet of life. People's understanding of their shoulder pain appears to be deeply rooted in a biomechanical view of pain, which influences their expectations relating to diagnosis and treatment.

Non-Specific Low Back Pain and Lumbar Radiculopathy: Comparison of Morphologic and Compositional MRI as Assessed by gagCEST Imaging at 3T

Using glycosaminoglycan Chemical Exchange Saturation Transfer (gagCEST) magnetic resonance imaging (MRI), this study comparatively evaluated the GAG contents of lumbar intervertebral disks (IVDs) of patients with non-specific low back pain (nsLBP), radiculopathy, and asymptomatic volunteers to elucidate the association of clinical manifestation and compositional correlate. A total of 18 patients (mean age 57.5 ± 22.5 years) with radiculopathy, 16 age-matched patients with chronic nsLBP and 20 age-matched volunteers underwent standard morphologic and compositional gagCEST MRI on a 3T scanner. In all cohorts, GAG contents of lumbar IVDs were determined using gagCEST MRI. An assessment of morphologic IVD degeneration based on the Pfirrmann classification and T2-weighted sequences served as a reference. A linear mixed model adjusted for multiple confounders was used for statistical evaluation. IVDs of patients with nsLBP showed lower gagCEST values than those of volunteers (nsLBP: 1.3% [99% confidence intervals (CI): 1.0; 1.6] vs. volunteers: 1.9% [99% CI: 1.6; 2.2]). Yet, IVDs of patients with radiculopathy (1.8% [99% CI: 1.4; 2.1]) were not different from patients with nsLBP or volunteers. In patients with radiculopathy, IVDs directly adjacent to IVD extrusions demonstrated lower gagCEST values than distant IVDs (adjacent: 0.9% [99% CI: 0.3; 1.5], distant: 2.1% [99% CI: 1.7; 2.5]). Advanced GAG depletion in nsLBP and directly adjacent to IVD extrusions in radiculopathy indicates close interrelatedness of clinical pathology and compositional degeneration.

An evaluation of MRI lumbar spine scans within a community-based diagnostic setting

BACKGROUND

With an ongoing move towards more management of patients within the community setting, demand for magnetic resonance imaging (MRI) is increasing and commonly used in lower back conditions. There is well recorded overuse of MRI in this scenario which goes against evidence-based practice and adds to rising healthcare costs.

METHODS

The study was a retrospective review of lumbar spine MRI scans performed within a community-based setting over an 18-month period. The review took a randomised purposive sample of patients (n = 450); looking at adherence to, and relevance of, guidelines in managing lower back conditions. Data extracted provided information on demographics and prevalence of clinical presentation and report observations.

RESULTS

There is variation in practice and utlisation of MRI with this patient group which warrants further exploration. Results support inappropriate use, lacking adherence to guidelines and pathways, leading to unnecessary imaging. 46% of referrals were considered clinically justified with 38% of report findings considered abnormal and of clinical relevance. Chi-square and binomial logistic regression were used to assess the significance and relationship of any factors on referral justification and report outcome. No difference was found between type of referrer, with patient age and leg symptoms being significant factors.

CONCLUSION

The study highlights the opportunity to integrate better referral criteria to improve referral quality, its suitability and the relevance of final reports. In the current climate this would help manage appropriate use of imaging resources during the post COVID-19 pandemic recovery phase, as well as support recommendations regarding diagnostic reform and a move towards more community-based diagnostics.

Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review

BACKGROUND

Musculoskeletal (MSK) pain is one of the most common reasons for primary care consultation, particularly pain in the lower back (LBP), knee and shoulder. The use of diagnostic imaging for MSK pain is increasing, but it is unclear whether this increase is justified on the basis of clinical practice guideline (CPG) recommendations.

AIM

To identify and map the content of CPGs that informs the use of diagnostic imaging in those with nontraumatic LBP, knee and shoulder pain in primary and intermediate care in the UK.

DESIGN AND SETTING

A scoping review of CPGs.

METHODS

This scoping review was conducted and is reported in accordance with PRISMA guidance. A broad search strategy included electronic searches of MEDLINE, CINAHL, PsychINFO and SPORTDiscus from 2009 to 17 April 2019. This was conducted alongside a search of guideline repositories and was combined with a snowball search of Google, relevant professional bodies and use of social media.

RESULTS

31 relevant CPGs were included. Routine use of diagnostic imaging for those with nontraumatic LBP, knee or shoulder pain is generally discouraged in primary care or intermediate care. Diagnostic imaging should be reserved for when specific or serious pathology is suspected or where the person is not responding to initial nonsurgical management and the imaging result is expected to change clinical management decisions.

CONCLUSION

Diagnostic imaging should not be routinely requested in primary or intermediate care for nontraumatic LBP, knee or shoulder pain. CPGs do not justify the increasing imaging rates in the UK for MSK pain.

Beliefs about the body and pain: the critical role in musculoskeletal pain management

BACKGROUND

Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by pain. Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability. Clinical guidelines recommend addressing unhelpful beliefs as the first line of treatment in all patients presenting with musculoskeletal pain. However, many clinicians hold unhelpful beliefs themselves; while others feel ill-equipped to explore and target the beliefs driving unhelpful responses to pain. As a result, clinicians may reinforce unhelpful beliefs, behaviours and resultant disability among the patients they treat.

METHODS

To assist clinicians, in Part 1 of this paper we discuss what beliefs are; how they are formed; the impact they can have on a person's behaviour, emotional responses and outcomes of musculoskeletal pain. In Part 2, we discuss how we can address beliefs in clinical practice. A clinical case is used to illustrate the critical role that beliefs can have on a person's journey from pain and disability to recovery.

CONCLUSIONS

We encourage clinicians to exercise self-reflection to explore their own beliefs and better understand their biases, which may influence their management of patients with musculoskeletal pain. We suggest actions that may benefit their practice, and we propose key principles to guide a process of behavioural change.

Utilization Review in Workers' Compensation: Review of Current Status and Recommendations for Future Improvement

: Utilization review (UR) is a process that assesses aspects of a treating provider's care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc, concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers' compensation (WC) system and is mandated in several states and jurisdictions. This guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) reviews structural elements of UR programs and proposes a possible template for operational standards. UR has a unique role in protecting patients and educating providers on evidence-based guidelines, new research, and best practices.

Health care personnel's perception of guideline implementation for musculoskeletal imaging: a process evaluation

Background

The increasing complexity and variability in radiology have significantly fueled the need for guidelines. There are many methods for disseminating and implementing guidelines however; and obtaining lasting changes has been difficult. Implementation outcome is usually measured in a decrease in unwarranted examinations, and qualitative data are rarely used. This study’s aim was to evaluate a guideline implementation process and identify factors influencing implementation outcome using qualitative data.

Methods

Seven general practitioners and five radiological personnel from a Norwegian county participated in four focus group interviews in 2019. The data were analyzed using qualitative content analysis, where some categories were predetermined, while most were drawn from the data.

Results

Four main categories were developed from the data material. 1) Successful/unsuccessful parts of the implementation, 2) perceived changes/lack of changes after the implementation, 3) environment-related factors that affected guideline use, and 4) User related factors that affect guideline use.

Conclusions

Our findings show that clinical guideline implementation is difficult, despite the implementation strategy being tailored to the target groups. Several environment- and user-related factors contributed to the lack of changes experienced in practice for both general practitioners and radiological personnel.

Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016

BACKGROUND

Low Back Pain (LBP) is associated with an increase in disability-adjusted life years, and increased risk of disability retirement and greater absenteeism in Brazil. Hence, evidence on healthcare and lost productivity costs due to LBP is of utmost importance to inform decision-makers.

METHODS

Cost-of-illness study with top-down approach, and societal perspective. We extracted data from National databases, considering the period 2012-2016. Outpatient expenses included clinical, surgical, diagnosis, orthosis/prosthetics, and complementary actions. Inpatient care expenses included hospital and professional services, intensive care unit, and companion stay. For productivity losses, duration of work absence and associated information (work-related and non-work-related; value of the sickness absence benefit; age; gender; and economic activity) were analyzed. Lost productivity costs were calculated multiplying the absence from work (days) by the daily-benefit.

RESULTS

The societal costs amounted to US$ 2.2 billion, and productivity losses represented 79% of the costs. Total healthcare expenses were estimated to US$ 460 million. We found more than 880,000 diagnostic images. Individuals with LBP were in total 59 million days absent from work between 2012-2016. The mean lost days absent from work per person, for each year investigated was, respectively, 88; 84; 83; 87; and 100. Men were more days absent from work than women. In addition, rural workers presented greater absence from work compared to other professional activities.

CONCLUSION

Healthcare expenses and lost productivity costs due to LBP were substantial, hence, there is a need for improvement of health services and policies to deal with this increasing burden of illness. We found an extensive use of diagnostic imaging, which is rather discouraged by clinical guidelines. We assume that men were experiencing high levels of back pain disability compared with women, as they presented greater absenteeism and higher lost productivity costs.

'My hip is damaged': a qualitative investigation of people seeking care for persistent hip pain

OBJECTIVES

Clinicians who use the biopsychosocial approach to manage musculoskeletal pain disorders aim to understand how patients make sense of their symptoms. Treatment includes targeting the negative beliefs and coping responses that can lead to progressive pain and disability. We aimed to explore how people seeking care for persistent hip pain and disability make sense of their symptoms.

METHODS

Cross-sectional qualitative study. People were eligible if they were aged ≥18 years, were consulting an orthopaedic surgeon for persistent hip pain and offered a non-surgical intervention. Data were collected through interviews that explored patients' beliefs about the identity (diagnosis), causes, consequences, timeline and controllability of their symptoms, their strategies to cope with pain and their experiences in seeking healthcare. Transcribed interview data were analysed thematically using a framework approach.

RESULTS

Sixteen people (median age=51, range=33-73 years; median duration hip pain=3 years, range=3 months-20 years) participated. Most participants (10/16) believed their pain was caused by an exercise-related injury. Because of the results of imaging and interactions with healthcare professionals, all participants believed they had damaged hip structures. All described ineffective strategies to manage their pain and multiple failed treatments. For many (7/16), a lack of control over symptoms threatened their physical and mental health.

CONCLUSIONS

The way participants with persistent hip pain and disability made sense of their symptoms contributed to them avoiding physical activity, and it impaired their sleep, emotional well-being and physical health.

The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.

Experience of living with knee osteoarthritis: a systematic review of qualitative studies

OBJECTIVES

Systematically review the qualitative literature on living with knee osteoarthritis from patient and carer perspectives.

DESIGN

Systematic review of qualitative studies. Five electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, SPORTDiscus) were searched from inception until October 2018. Data were synthesised using thematic and content analysis.

PARTICIPANTS

Studies exploring the experiences of people living with knee osteoarthritis, and their carers were included. Studies exploring experiences of patients having participated in specific interventions, including surgery, or their attitudes about the decision to proceed to knee replacement were excluded.

RESULTS

Twenty-six articles reporting data from 21 studies about the patient (n=665) and carer (n=28) experience of living with knee osteoarthritis were included. Seven themes emerged: (i) Perceived causes of knee osteoarthritis are multifactorial and lead to structural damage to the knee and deterioration over time (n=13 studies), (ii) Pain and how to manage it predominates the lived experience (n=19 studies), (iii) Knee osteoarthritis impacts activity and participation (n=16 studies), (iv) Knee osteoarthritis has a social impact (n=10 studies), (v) Knee osteoarthritis has an emotional impact (n=13 studies), (vi) Interactions with health professionals can be positive or negative (n=11 studies), (vii) Knee osteoarthritis leads to life adjustments (n=14 studies). A single study reporting the perspectives of carers reported similar themes. Psychosocial impact of knee osteoarthritis emerged as a key factor in the lived experience of people with knee osteoarthritis.

CONCLUSIONS

This review highlights the value of considering patient attitudes and experiences including psychosocial factors when planning and implementing management options for people with knee osteoarthritis. Trial registrationnumber CRD42018108962.

The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain

BACKGROUND

Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.

OBJECTIVE

To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.

DESIGN

Retrospective observational cohort.

METHODS

Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.

RESULTS

From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).

CONCLUSIONS

MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.

An online investigation into the impact of adding epidemiological information to imaging reports for low back pain

Degenerative changes commonly feature on spinal images and are often identified in the imaging reports of pain-free individuals. Many of these findings relate to "normal" age-related characteristics, however are frequently interpreted as implying abnormality and may adversely influence patient outcomes. The aim of this study was to investigate the impact of adding epidemiological information to lumbar imaging reports in a general adult population. This study was an online, scenario-based, randomised experiment. Participants were presented with a "virtual patient" scenario via an online survey and then randomly allocated to either receive a standard imaging report or a standard report with additional epidemiological information. The primary outcome was a composite "back-related perceptions" (BRP) score. Data from 247 participants (72% female) were included in the analysis. There was a small effect of group on BRP [F(12,444) = 6.75, p = 0.010] with participants who received the additional epidemiological information demonstrating more positive perceptions. Including epidemiological information in spinal imaging reports positively impacted "virtual-patient" perceptions in an online scenario-based study. This finding suggests that implementing a simple imaging reporting strategy may be reassuring and should be further considered for its potential to positively impact patient outcomes. Further research is warranted in clinical populations.

How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years

Objectives

To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.

Data sources

Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.

Eligibility criteria for selecting studies

Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.

Results

45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.

Summary/conclusion

One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.

Trial registration number

CRD42016041987.

Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis

BACKGROUND CONTEXT

The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear.

PURPOSE

This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed.

DESIGN

This is a systematic review and meta-analysis.

PATIENT SAMPLE

The sample comprised patients with LBP presenting to primary care.

OUTCOME MEASURES

Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures.

METHODS

MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system.

RESULTS

Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology.

CONCLUSIONS

Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.

Using behaviour change theory and preliminary testing to develop an implementation intervention to reduce imaging for low back pain

BACKGROUND

Imaging is overused in the management of low back pain (LBP). Interventions designed to decrease non-indicated imaging have predominantly targeted practitioner education alone; however, these are typically ineffective. Barriers to reducing imaging have been identified for both patients and practitioners. Interventions aimed at addressing barriers in both these groups concurrently may be more effective. The Behaviour Change Wheel provides a structured framework for developing implementation interventions to facilitate behavioural change. The aim of this study was to develop an implementation intervention aiming to reduce non-indicated imaging for LBP, by targeting both general medical practitioner (GP) and patient barriers concurrently.

METHODS

The Behaviour Change Wheel was used to identify the behaviours requiring change, and guide initial development of an implementation intervention. Preliminary testing of the intervention was performed with: 1) content review by experts in the field; and 2) qualitative analysis of semi-structured interviews with 10 GPs and 10 healthcare consumers, to determine barriers and facilitators to successful implementation of the intervention in clinical practice. Results informed further development of the implementation intervention.

RESULTS

Patient pressure on the GP to order imaging, and the inability of the GP to manage a clinical consult for LBP without imaging, were determined to be the primary behaviours leading to referral for non-indicated imaging. The developed implementation intervention consisted of a purpose-developed clinical resource for GPs to use with patients during a LBP consult, and a GP training session. The implementation intervention was designed to provide GP and patient education, remind GPs of preferred behaviour, provide clinical decision support, and facilitate GP-patient communication. Preliminary testing found experts, GPs, and healthcare consumers were supportive of most aspects of the developed resource, and thought use would likely decrease non-indicated imaging for LBP. Suggestions for improvement of the implementation intervention were incorporated into a final version.

CONCLUSIONS

The developed implementation intervention, aiming to reduce non-indicated imaging for LBP, was informed by behaviour change theory and preliminary testing. Further testing is required to assess feasibility of use in clinical practice, and the effectiveness of the implementation intervention in reducing imaging for LBP, before large-scale implementation can be considered.