[

clinical commentary

TIMOTHY W. FLYNN, PT, PhD1 BRITT SMITH, PT, DPT2 ROGER CHOU, MD3

Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good

ow back pain (LBP) is common and costly. Approximately one quarter of adults in the United States have reported having LBP lasting at least 1 whole day in the past 3 months,20 and 2% of all physician office visits are for low back complaints.43 In 2005, total healthcare expenditures in the United States for LBP were estimated at $85.9 billion.43 LBP is the most frequent disorder managed by physical therapists,
accounting for 50% of all patients seeking outpatient physical therapy care. In the US, physical therapists are increasingly either the point of clinical entry or the main clinical contact for patients with low back complaints.45 Physical
TTSYNOPSIS: The rate of lumbar spine magnetic

therapists have most extensively occupied this role in the US Army, where, since the early 1970s, they have served as nonphysician healthcare providers or physician extenders, when performing primary care (ie, evaluation
crease the risk of patient harm and contributes to the recent large increases in healthcare costs; (3) to provide physical therapists with clear guidelines to educate patients on both appropriate imaging and information to dampen the potential negative effects of imaging on patients perceptions and health; and (4) to present an example of a successful clinical pathway that has reduced imaging and improved outcomes.

resonance imaging in the United States is growing at an alarming rate, despite evidence that it is not accompanied by improved patient outcomes. Overutilization of lumbar imaging in individuals with low back pain correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years. Furthermore, a patients knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity. The purpose of this clinical commentary is as follows: (1) to describe an outline of the appropriate use, as defined in recent guidelines, of diagnostic imaging in patients with low back pain; (2) to describe how inappropriate use of lumbar spine imaging can in-

TTLEVEL OF EVIDENCE: Diagnosis/progno-

sis/therapy, level 5. J Orthop Sports Phys Ther 2011;41(11):838-846, Epub 3 June 2011. doi:10.2519/jospt.2011.3618

TTKEY WORDS: lumbar spine, MRI, magnetic

resonance imaging, overutilization, screening, prognosis

and treatment for patients with neuromusculoskeletal conditions such as LBP).33 US Army physical therapists are credentialed to refer patients to radiology for diagnostic imaging tests (radiographs, magnetic resonance imaging [MRI], computed tomography [CT] scans, and bone scans).53 The implementation of these neuromusculoskeletal management programs has further expanded into other healthcare systems.45 This evolving role of physical therapists in the management of LBP is consistent with the American Physical Therapy Associations Vision 2020 statement, which calls for consumers to have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services, including status as practitioners of choice in patients/clients health networks holding all privileges of autonomous practice.3 Finally, a projected shortage of primary care physicians for adults is looming.25 It is, therefore, probable that physical therapists will be the point of entry for increasing numbers of individuals with low back disorders. As such, it is imperative that physical therapists have a keen understanding of the appropriate and in-

Distinguished Professor, Rocky Mountain University of Health Professions, Provo, UT. 2Physical Therapist, SOAR Physical Therapy, Grand Junction, CO. 3Associate Professor, Oregon Health & Science University, Portland, OR. Address correspondence to Dr Timothy W. Flynn, Rocky Mountain University of Health Professions, 561 East 1860 South, Provo, UT 84606. E-mail: tim@colpts.com
1

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appropriate uses of diagnostic imaging in individuals with LBP. Currently, physical therapists in some healthcare systems are responsible for ordering images. Thus it is essential that physical therapists in these settings are up to date on current guidelines.45 Additionally, all physical therapists involved in the management of low back disorders play a critical role in patient education and potentially have a strong influence on patient expectations regarding imaging. It is incumbent upon all clinicians involved in low back pain management to convey a consistent, evidence-based message regarding the appropriate use of imaging and to assist in the reduction of unnecessary imaging. Therefore, the purpose of this commentary is to review the recommended guidelines for medical imaging in individuals with LBP and to discuss the risks and costs of inappropriate imaging. In addition, we will discuss educational strategies that may reassure and empower patients with knowledge of the benefits and risks of diagnostic imaging.

APPROPRIATE USE OF DIAGNOSTIC IMAGING IN PATIENTS WITH LBP

n 2007, the American College of Physicians and the American Pain Society published a joint clinical practice guideline on the diagnosis and management of LBP.12 The guideline provides updated evidence on appropriate diagnostic imaging in patients with LBP. The 3 key recommendations regarding diagnostic imaging are the following: 1.  Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (grade: strong recommendation, moderate-quality evidence). 2.  Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history

and physical examination (grade: strong recommendation, moderatequality evidence). 3.  Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography, only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (grade: strong recommendation, moderate-quality evidence). The evidence supporting these recommendations includes a number of randomized clinical trials. Recently, a meta-analysis of 6 randomized trials of patients (n = 1804) with primarily acute or subacute LBP was conducted.10 The patients in these trials had no clinical or historical features that suggested a serious underlying condition. The metaanalysis indicated that there was no difference in outcomes for pain, function, quality of life, or overall patient-rated improvement between those who were provided usual care without routine lumbar imaging (radiography, MRI, or CT) versus those provided with usual care and the addition of lumbar imaging.10 In fact, for short-term outcomes, trends slightly favored usual care without routine imaging. Furthermore, routine imaging was not associated with psychological benefits,10 despite some clinicians perceptions that it might help alleviate patient fear and worry about back pain.50 Importantly, in 4 trials (n = 399) included in the meta-analysis that performed imaging in all patients or followed patients for at least 6 months, no serious underlying conditions were found. This is further evidence that imaging may not be necessary in the absence of suggestive clinical or historical features. The vast majority of patients with LBP do not need diagnostic imaging, and an even smaller percentage require advanced imaging, such as MRI. The results of the history and physical examination should determine if imaging is needed.

Consistent with the ongoing work on subgrouping and staging patients with LBP, the first step is to determine whether the patient is appropriate for physical therapy-only management or whether further diagnostic workup is warranted.16 The key component in this step is identifying red flags or clinical features that represent serious underlying pathology. TABLE provides the American College of Physicians/American Pain Society evidencebased guidelines for ordering imaging when key historical or physical examination features are present. In a primary care setting, the prevalence rate of LBP due to cancer is approximately 0.7%, that of compression fracture 4%, and spinal infection 0.01%.35 Estimates for prevalence of ankylosing spondylitis for patients seen in primary care range from 0.3% to 5%.35,52 Routine screening of risk factors for cancer and infection should be considered standard of care in LBP management in physical therapist practice. In a large, prospective study from a primary care setting, a history of cancer (positive likelihood ratio, 14.7), unexplained weight loss (positive likelihood ratio, 2.7), failure to improve after 1 month (positive likelihood ratio, 3.0), and age older than 50 years (positive likelihood ratio, 2.7) were each associated with a higher likelihood for cancer.18 In patients with a history of cancer (not including nonmelanoma skin cancer) the posttest probability of cancer presenting with back pain increases from approximately 0.7% to 9%. This means that nearly 1 in 10 of these patients would have a metastatic cancer and thus the physical therapist should recommend immediate imaging in this subgroup of patients.34 Conversely, in patients with any 1 of the other 3 risk factors (unexplained weight loss, age over 50, failure to improve after 1 month) the likelihood of cancer only increases to approximately 1.2%. In this instance, a more pragmatic approach involving close monitoring and an expectation of symptom improvement during rehabilitation is warranted.38,51 If little to no improvement is noted, further

journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 839

[
TABLE
Possible Cause/Key Features on Physical Examination History Cancer History of cancer with new onset of LBP Unexplained weight loss, failure to improve after 1 mo, age over 50 y Multiple risk factors present Vertebral infection Fever, intravenous drug use, recent infection Cauda equina syndrome Urinary retention, motor deficits at multiple levels, fecal inontinence, saddle anesthesia Vertebral compression fracture History of osteoporosis, use of corticosteroids, older age Anklylosing spondylitis Morning stiffness, improvement with exercise, alternating buttock pain, awakening due to back pain during the second part of the night, younger age Severe/progressive neurological deficits Progressive motor weakness

clinical commentary

Screening for Red Flags

Imaging MRI

Additional Studies

Lumbosacral plain radiography ESR Plain radiography or MRI MRI MRI ESR and/or CRP None

Lumbosacral plain radiography None

Anterior-posterior pelvis plain radiography

ESR and/or CRP, HLA-B27

one factor remains low. Additional imaging guideline resources are available from the American College of Radiology and include free online availability.2,15 In summary, the guidelines provide a clear and succinct guide to appropriate imaging. As noted above, the use of imaging in the acute and subacute stages (up to 12 weeks) of an episode of LBP is only warranted as a method to rule out serious pathology and not one that should be employed to guide routine therapeutic decision making. Therefore, in the early management of an LBP episode, it is incumbent on the physical therapist to explain to the patient that early, routine imaging and other tests usually cannot identify a precise cause, do not improve patient outcomes, and incur additional expenses.12

MRI

Consider EMG/NCV

INAPPROPRIATE USE OF LUMBAR SPINE IMAGING: HARMFUL EFFECTS

Abbreviations: CRP, C-reactive protein; EMG/NCV: electromyography/nerve conduction velocity; ESR, erythrocyte sedimentation rate; HLA-B27, human leukocyte antigen B27; LBP, low back pain; MRI, magnetic resonance imaging. Adapted with permission from Chou R, et al.12

diagnostic testing to rule out cancer is appropriate. There are 2 emergent albeit rare conditions, cauda equina and vertebral infection, in which even a short delay in diagnosis can have a negative effect on patient outcomes. Key clinical features include new urinary retention, saddle anesthesia, fecal incontinence, or fever (especially in patients with risk factors for bacteremia).13,46 Immediate imaging is also indicated for severe or progressive neurologic deficits, such as progressive motor weakness at a single level or deficits at multiple spinal levels. When managing patients with LBP, physical therapists are at a distinct advantage in being able to monitor changes in physical status over time. Frequently, patients with LBP are undergoing a course of care in which the physical therapist is able to reassess their neurological status on an ongoing basis. Thus, in

the absence of an emergent condition, such as in patients without signs of neurological compromise but who may have features suggestive of a compression fracture or ankylosing spondylitis, the physical therapist is frequently able to initiate treatment without the need for imaging. Additionally, there is no evidence that it is dangerous for patients with a compression fracture with no spinal instability or neurological compromise to participate in physical therapy, and physical therapy is a first-line therapy for those with ankylosing spondylitis.14 Thus appropriate physical therapy can be initiated, and further diagnostic workup is based on a response to treatment and patient outcome. For example, if the patient is failing to improve with 4 weeks of physical therapy intervention, then diagnostic imaging may be considered; though, as previously noted, the likelihood of significant underlying disease based on this

iagnostic imaging in individuals with LBP should only be used if the results of the image lead to a clinical decision that results in improved patient outcomes. This statement appears both logical and obvious; however, data suggest that in the current US healthcare system this is clearly not the guiding principle.22,42 A recent study in the Journal of the American College of Radiology found that 26% of medical images ordered were inappropriate, and the authors cited MR for acute back pain without conservative therapy as a criterion for identifying inappropriate utilization.41 The study found a 53% inappropriate referral rate for CT and 35% inappropriate referral rate for MRI.41 MRI may, in fact, facilitate the medicalization of LBP, due to its visually exquisite depiction of pathoanatomy.8 In fact, it is questionable whether the term pathoanatomy or abnormality appropriately describes what could be considered nonpathological or normal, age-related or degenerative changes. For example, among asymptomatic persons 60 years

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or older, 36% had a herniated disc, 21% had spinal stenosis, and over 90% had a degenerated or bulging disc.6 Carragee et al9 performed MRIs at baseline (no symptoms of LBP) and then a repeat MRI if a patient developed an episode of LBP. The sample included 200 patients followed for 5 years.9 In the patients that went on to develop clinically serious LBP during the subsequent 5 years, 84% had unchanged or improved lumbar imaging abnormalities findings after symptoms developed. Furthermore, at baseline (no LBP), there was a high incidence of what in most studies would appear to be potentially serious pathology: nearly 50% had either disc protrusion or extrusion, nearly 30% had annular fissures, and there was potential root irritation in 22%.9 Thus over 90% of individuals had imaging findings without any significant low back symptoms, indicating that the association between such findings and symptoms is tenuous.9 Jarvik et al,36 in a 3-year follow-up of a cohort of patients that had no LBP at baseline at the Veterans Administration Hospital, reported that only 2 MRI findings, canal stenosis and nerve root contact, predicted future episodes of LBP. In fact, a history of depression was more predictive than either of these 2 MRI findings.36 To date, there is no evidence that selecting therapeutic interventions based on the presence of common imaging findings in persons with nonradicular LBP improves outcomes.12 Therefore, a decision to order imaging requires clinicians to equally consider the potential harm that may occur as a result of excessive imaging. The potential harm associated with overimaging of lumbar spine in patients with LBP includes radiation exposure (lumbar radiographs and CT),5,23 exposure to iodinated contrast (CT),1 increased risk of surgery (MRI),37,42 and labeling when patients are told they have an abnormality (lumbar radiographs and MRI).24,32,39 In 2007, 2.2 million lumbar CT scans were performed in the US. Based on the radiation exposure patients received, these CT scans were projected

A
1800

1500

1420

Lumbar MRIs, Thousands

1200

900

600

300

349

0 1994 1996 1998 2000 2002 2004

B
70

61.1
60 50

Fusions per 100 000

40 30

20 10

13.9

0 1988 1990 1992 1994 1996 1998 2000

FIGURE 1. (A) Trends in lumbar MRIs and (B) lumbar fusions in the Medicare population. Used with permission
from Deyo et al.21

to cause 1200 additional future cancers.5 It is generally believed that at least a third of these scans were not medically necessary.7 Though much less of a concern, gadolinium-based MR contrast agents carry some risk.15 Generally, these agents remain very safe. However, it is recommended that gadolinium contrast agents should not be administered to patients with either acute or significant chronic kidney disease.15 Lumbar spine radiographs provide an estimated radiation dose equivalent to six months of background radiation (radiation associated with normal daily

living).48 While the risk is considered very low, it does incur a 1 in 100000 to 1 in 10000 risk of fatal cancer.48 The average radiation exposure from lumbar radiography is 75 times higher than that of a chest radiograph, which is particularly concerning in young women, given the difficulty in effectively shielding the gonads.23 It is estimated that female gonadal radiation from lumbar radiography is equivalent to a daily chest radiograph for several years.35 Large variability in lumbar spine surgical rates is now well established.57,56 Though direct causality cannot be estab-

journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 841

clinical commentary

FIGURE 2. (A) Anterior-posterior radiograph demonstrating a large osteophyte complex at L3-4 on the left. (B)
Lateral radiograph demonstrating retrolisthesis at L1-2 and L2-3, with evidence of degenerative disk disease at several levels.

lished, there is a strong association between rates of advanced spine imaging and rates of surgery.54 FIGURE 1A displays the increasing utilization of lumbar MRI in the Medicare population from 1994 to 2004, and FIGURE 1B displays the increased utilization of spinal fusion in this same population from 1988 to 2001.19 In Medicare beneficiaries, the rates of spine MRI utilization accounted for 22% of the variability in overall spine surgery rates, which was more than twice the variability accounted for by differences in patient characteristics.42 Furthermore, the use of MRI versus a lumbar radiograph early in the course of an episode of LBP resulted in a 3-fold increase in surgical rates, with no improvements in outcomes in the subsequent year.37 Unnecessary lumbar spine surgery is costly and has significant side effects, including death. Life-threatening complications are particularly common in older adults, ranging from 2.3% among patients having decompression alone to 5.6% among those having complex fusions.44 Furthermore, in the adult population, the likelihood of multiple spinal surgeries is considerable. Martin et al44 reported that patients who had surgery between 1990 and 1993 had

a 19% cumulative incidence of reoperation during the subsequent 11 years. In addition to the potentially harmful effects of radiation and the risks associated with spinal surgery, there is evidence that telling patients that they have an imaging abnormality has negative effects related to labeling.24 For example, Ash and colleagues4 performed MRIs on 246 patients with acute LBP or sciatica and subsequently randomized them to receive the results of the image or not. At 1 year, both groups had similar clinical outcomes; however, self-rated general health improved significantly more in the group that remained blind to the results of their MRI.4

PLACING IMAGING RESULTS IN THE APPROPRIATE CONTEXT: PATIENT EDUCATION

maging can lead to additional tests, follow-up, and referrals, and may result in an invasive procedure of limited or questionable benefit.11 Furthermore, it can be very difficult to counteract negative consequences following an imaging finding of purported pathology, such as a

herniated or degenerated disc. A patient will typically focus on this as the source of the problem. Therefore, the therapist needs to provide clear information to reverse the potentially negative effects that knowledge of imaging abnormalities may have on perceptions of health. However, it goes beyond just imparting information. The physical therapist must frequently change the patients beliefs that their LBP will not improve unless the image improves. We should reiterate to the patient that the image of a disc lesion of some sort represents a picture of a single moment in time and that we have no compelling evidence that this indicates or indicts them to a prolonged course of impairment/disability. They require frequent reassurance that there is no serious damage or disease and that the overall prognosis is goodfor example, a consistent positive message informing the patient that, regardless of the imaging findings, the vast majority of low back pain resolves fairly quickly, the risk of chronic LBP is very low, and, therefore, the odds for recovery are good. It is particularly important to identify individuals with high fear-avoidance beliefs regarding the effects of activity and work on their LBP, in order to institute an aggressive program to break the cycle of inactivity, disuse, and increased disability.40 In these individuals, specific programs that focus on correcting mistaken beliefs about the negative effects of activity or exercise on the back and engage them in active physical therapy are warranted.28-30 In addition, a psychosocial education program can have a positive effect on LBP beliefs in a primary prevention setting.29 It may be helpful during the education process to provide patients with examples of pathology in imaging that is not associated with pain and disability. Contrast the radiographs in FIGURE 2 and MR images in FIGURE 3 from a 62-year-old male who had bilateral hip replacements in 2002, with FIGURE 4, which are MRI images from a 32-year-old male with chronic LBP. The images from the 62-year-old

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male demonstrate significant lumbar degenerative changes associated with intermittent symptoms, which he managed with exercise, yoga, and occasional physical therapy. He had an episode of LBP in the summer of 2010, which he recalled as sharp LBP after canoeing and hiking for 2 weeks. He was able to work through his pain with ibuprofen and stretching during his trek. The patient subsequently had a full recovery from this exacerbation after 9 sessions of physical therapy (Oswestry Low Back Pain Disability Questionnaire score, 46% at worst and 6% at discharge). He was contacted 6 months after his initial visit and noted that he had recently completed a 2-week backpacking hike of the United States Continental Divide and had no current LBP. The 32-year-old automobile parts store manager had a history of chronic LBP. He was off-work for disability and presented in September 2009 with severe LBP. In FIGURE 4 are MRIs from 2009 that were interpreted as relatively unremarkable, with degenerative disc disease at L4-5 and L5-S1, and mild disc protrusion at L4-5. His central canal is sufficient at all levels. He was not deemed a surgical candidate, and was referred to physical therapy. The patient attended a total of 24 sessions of physical therapy over a 9-month period that focused on core strengthening and conditioning. His Oswestry improved from 84% to 36% at the time of discharge. Interestingly, this patient had low Fear-Avoidance Belief Questionnaire (FABQ) physical activity (10 of 24) and work scale (9 of 42) scores. He returned to work at a new job managing automobile parts with a new company in February 2010, with continued moderate levels of LBP and disability. Clearly, this patients MRI results are not reflective of serious pathology; yet he continued to have LBP, whereas the 62-year-old male in our first example had the proverbial spine of an 85-year-old and enjoyed a robust physical lifestyle. The use of such examples may help patients to understand that imaging findings do not determine the extent of pain

FIGURE 3. (A) T2 sagittal magnetic resonance image demonstrating herniated nucleus pulposus at L2-3 with
canal stenosis. (B) T2 transverse magnetic resonance image of L2-3 with severe central canal stenosis.

FIGURE 4. (A) T2 sagittal magnetic resonance image with degenerative disc disease in the lower lumbar spine
and mild disc protrusion at L4-5. (B) T2 transverse magnetic resonance image with moderate broad based disc protrusion at L4-5.

or limitations, and that the focus should be on maximizing function. Ultimately, recovery and relief of pain depend on getting the patient active again and restoring normal function.55 Educating patients on the facts about the use and limitations of lumbar spine imaging is imperative. Wennberg argues that the shift to shared decision making and preferencesensitive care, away from paternalistic, delegated decision making and supply-sensitive care, will actually reduce utilization rates of services (eg, surgery and imaging), if we educate the patients about the facts.58 Evidence supporting

this assertion includes a clinical trial, in which patients with LBP who were candidates for elective spine surgery were randomized to either read a brochure and watch a video with actual patients describing their preferences and their decisions on whether to have surgery or not, versus a control group who received only the brochure.17 The written booklet contained anatomic illustrations of the lumbar spine, a discussion of surgical and nonsurgical treatments for herniated disks and spinal stenosis, a general description of expected outcomes, and a short self-test on material in the booklet.

journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 843

clinical commentary
Old Approach Average cost, $2100-$2200 The initial meeting might not happen for up to a month, and then there is no set procedure for treatment

The video program included animated graphics of spinal anatomy, a discussion of problems that cause back pain, and a discussion of ambiguities in diagnosis. Outcome probabilities for surgical and nonsurgical care at 1, 4, and 10 years were presented, along with interviews from real patients who had experienced either good or bad outcomes of surgical or nonsurgical care. The patients who watched the video scored higher on a knowledge test for decision-making information and the cohort of patients with a herniated disc who watched the video were less likely to choose surgery than patients who received only the brochure (32% versus 47%).17 The 1-year outcomes for the patients in either group who decided against surgery were the same as the patients who had surgery, thus the surgery rates were reduced without adverse outcomes.17 Wennberg58 suggests that a central impediment to developing shared decision making is a reimbursement system that rewards physicians for performing an operation but does not reward the physician for taking the time to learn what patients want. In high-volume disorders, LBP in particular, changing the system of healthcare delivery is crucial to implementing patient-preference-driven, shared decision making and reducing overutilization of imaging resources. A system that places physical therapists as first providers for back pain has the potential to improve outcomes and reduce overutilization of finite and expensive resources, while providing both evidence-based and preferencesensitive healthcare.

New Approach Average cost, $900-$1000 Immediately see physical therapist Initiate evidence-based conservative program Physical therapy

Patients with complicated back pain are sent for additional treatment Initial meeting with doctors Patient follows up with doctors Patient might see a specialist Patient might undergo diagnostics, such as MRI

FIGURE 5. Virginia Mason example for a pathway for LBP management.

POTENTIAL PATHWAYS TO LOWER IMAGING: THE VIRGINIA MASON EXAMPLE

hen used appropriately, diagnostic imaging in the early to middle stages of an individual presenting with LBP should be an infrequent occurrence. Multiple publications have called for an evidence-based approach when considering imaging

in patients with LBP.12,35,41,49 However, implementing this evidence into action has proven to be daunting, as rates of imaging continue to increase.21 A recent systematic review evaluated the effect of distributing educational materials to clinicians on rates of appropriate LBP imaging.26 The majority of the included studies observed no significant improvement in rates of appropriate imaging, and it is currently unclear whether educational materials are effective or not for changing LBP imaging behavior.26 An exception is the experience of the Virginia Mason Medical Center in Seattle, WA in changing the care pathway for individuals presenting with LBP.47 In the summer of 2004, the insurance company Aetna gave Virginia Mason notice that their specialty practices cost up to twice as much as other top local practices for the same care.27 This resulted in Virginia Mason studying the care process for LBP and noting a lack of standardized, evidence-based procedures. Though Virginia Mason physicians were salaried and had no direct financial incentive to run excess tests, many had gotten into the habit of ordering an MRI.27 The proposed solution was to change the pathway and implement an evidence-based

protocol with physical therapy upfront (FIGURE 5).27 The result was that, within a year, the number of individuals with LBP who received an MRI decreased from 15% to 10%.27 In addition, the cost of an episode of care was reduced from the $2100-$2200 to the $900-$1000 range, and the early initiation of physical therapy reduced the need for staff at the Virginia Masons chronic pain center, as fewer patients with LBP went on to that level of care.27 The new model resulted in only 6% of patients losing time from work, though further research should also report on additional patient-centered outcomes of this model of care. The challenges to implementing this example are significant, as there are many stakeholders in the LBP industry. The success of the program is based on the basic assumption that in the vast majority of patients with improving function, imaging is neither required nor appropriate. However, in the current healthcare climate, the implementation of this model requires collaboration among purchasers, health plans, and providers operating in an integrated delivery system, with all parties having access to detailed cost data, along with incentives structured so that more efficient providers retain some

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savings while increasing capacity. Furthermore, it is imperative that, if physical therapists serve as the initial point of entry, they are well versed in appropriate imaging guidelines and implement them appropriately.

CONCLUSION

hen used appropriately diagnostic imaging is an important component of patient care in individuals with low back complaints. The inappropriate use of lumbar spine imaging can increase the risk of patient harm and contributes to the recent large increases in healthcare costs. Physical therapists have an important role in educating the patient consumer and medical colleagues on appropriate imaging and the integration of the imaging findings in the overall context of patients function and disability. Future research should continue to explore clinical pathways that can reduce inappropriate imaging, decrease costs, and improve patient outcomes. t

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prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31:2724-2727. http://dx.doi. org/10.1097/01.brs.0000244618.06877.cd Deyo RA, Mirza SK, Turner JA, Martin BI. Over treating chronic back pain: time to back off? J Am Board Fam Med. 2009;22:62-68. http:// dx.doi.org/10.3122/jabfm.2009.01.080102 Di Iorio D, Henley E, Doughty A. A survey of pri mary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000;9:1015-1021. Fazel R, Krumholz HM, Wang Y, et al. Exposure  to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009;361:849857. http://dx.doi.org/10.1056/NEJMoa0901249 Fisher ES, Welch HG. Avoiding the unintended  consequences of growth in medical care: how might more be worse? JAMA. 1999;281:446-453. Freed GL, Stockman JA. Oversimplifying  primary care supply and shortages. JAMA. 2009;301:1920-1922. http://dx.doi.org/10.1001/ jama.2009.619 French S, Green S, Buchbinder R, Barnes H. In terventions for improving the appropriate use of imaging in people with musculoskeletal conditions. Cochrane Database of Syst Rev. 2010 Jan 20;(1):CD006094. Fuhrmans V. A novel plan helps hospital wean  itself off pricey tests. Wall Street Journal. 2007; 12 January:A1. George SZ, Fritz JM, Bialosky JE, Donald DA. The  effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976). 2003;28:2551-2560. http:// dx.doi.org/10.1097/01.BRS.0000096677.84605. A2 George SZ, Teyhen DS, Wu SS, et al. Psychoso cial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting. Eur Spine J. 2009;18:1050-1058. http:// dx.doi.org/10.1007/s00586-009-1016-7 George SZ, Wittmer VT, Fillingim RB, Robin son ME. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. J Orthop Sports Phys Ther. 2010;40:694-704. http://dx.doi. org/10.2519/jospt.2010.3396 George SZ, Zeppieri G. Physical therapy uti lization of graded exposure for patients with low back pain. J Orthop Sports Phys Ther. 2009;39:496-505. http://dx.doi.org/10.2519/ jospt.2009.2983 Gilbert FJ, Grant AM, Gillan MG, et al. Low back  pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial. Radiology. 2004;231:343-351. http:// dx.doi.org/10.1148/radiol.2312030886 Greathouse DG, Schreck RC, Benson CJ. The  United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys Ther. 1994;19:261-266.

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42. L  urie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976). 2003;28:616-620. http:// dx.doi.org/10.1097/01.BRS.0000049927.37696. DC 43.  Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664. http://dx.doi.org/10.1001/jama.299.6.656 44.  Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976). 2007;32:382-387. http://dx.doi.org/10.1097/01. brs.0000254104.55716.46 45.  Murphy BP, Greathouse D, Matsui I. Primary care physical therapy practice models. J Orthop Sports Phys Ther. 2005;35:699-707. 46.  OLaughlin SJ, Kokosinski E. Cauda equina syndrome in a pregnant woman referred to physical therapy for low back pain. J Orthop Sports Phys Ther. 2008;38:721. http://dx.doi.org/10.2519/ jospt.2008.0411 47.  Pham HH, Ginsburg PB, McKenzie K, Milstein A. Redesigning care delivery in response to a high-performance network: the Virginia Mason Medical Center. Health Aff (Millwood). 2007;26:w532-544. http://dx.doi.org/10.1377/ hlthaff.26.4.w532 48.  Radiological Society of North America, American College of Radiology. Radiation Exposure in X-ray and CT Examinations. Available at: http://www.radiologyinfo.org/en/safety/index. cfm?pg=sfty_xray. Accessed September 29, 2011, 49.  Roudsari B, Jarvik JG. Lumbar spine MRI for low back pain: indications and yield. AJR Am J Roentgenol. 2010;195:550-559. http://dx.doi. org/10.2214/AJR.10.4367 50.  Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for

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846 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy

jospt perspectives for patients

Low Back Pain

MRIs Should Be Used Sparingly in Patients With Low Back Pain

J Orthop Sports Phys Ther 2011;41(11):847. doi:10.2519/jospt.2011.0507

ow back pain is very common, with 80% of people experiencing back pain at least once in their lifetimes. The good news is that a thorough physical examination can often determine the best course of management and whether you require imaging (X ray, MRI, CT scans, etc) to rule out a serious problem. Often low back pain can be severe enough to make a patient think that an MRI is necessary. While MRI provides excellent pictures of your anatomy, it may not be able to

pinpoint the specific source of your pain. A clinical commentary published in the November 2011 issue of JOSPT summarizes research that describes how the increased use of unnecessary imaging may lead to less than favorable results. Specifically, the research shows that overuse of MRI for patients with low back pain is related to an increased rate of surgical procedures that have not consistently been shown to significantly reduce painful symptoms and improve daily function. NEW INSIGHTS
The authors summarized current clinical guidelines and available research on low back pain and diagnostic imaging (X rays, CT Scans, and MRIs). MRI findings of herniated lumbar disks are commonly seen in individuals with and without low back pain. Some studies show that up to 90% of healthy individuals over the age of 60 have findings of bulging discs on MRI. Further, the rapid decision to perform imaging following an acute episode of low back pain may not be justified or warranted, considering the fact that many patients show signs of recovery shortly after the onset of low back pain. While a referral for imaging is indicated to rule out serious problems, it should not be used as a method to guide routine decision making about how best to treat low back pain. It is estimated that half of all performed CT scans and one third of MRIs of the low back are not necessary. In fact, some individuals should not undergo an MRI scan. These patients include individuals who have older pacemakers, metal implants, shrapnel, or are in the first 12 weeks of pregnancy.

Examination

Physical therapy intervention

PRACTICAL ADVICE
Referral to physician specialist is made and potential imaging ordered if a serious underlying condition is suspected

DIAGNOSING AND TREATING LOW BACK PAIN. A person who experiences low back pain first visits his or her physical therapist who begins a conservative, evidence-based treatment program. If the case suggests an underlying condition or more complex source of the back pain, the patient may be sent to a physician specialist for further evaluation. This JOSPT Perspectives for Patients is based on an article by Flynn TW et al, titled Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder that Unnecessary Imaging May Do as Much Harm as Good (J Orthop Sports Phys Ther 2011;41(11):838-846. doi:10.2519/jospt.2011.3618) This Perspectives article was written by a team of JOSPTs editorial board and staff, with Deydre S. Teyhen, PT, PhD, Editor, and Jeanne Robertson, Illustrator. JOSPT PERSPECTIVES FOR PATIENTS is a public service of the Journal of Orthopaedic & Sports Physical Therapy. The information and recommendations contained here are a summary of the referenced research article and are not a substitute for seeking proper healthcare to diagnose and treat this condition. For more information on the management of this condition, contact your physical therapist or healthcare provider specializing in musculoskeletal disorders. JOSPT Perspectives for Patients may be photocopied noncommercially by physical therapists and other healthcare providers to share with patients. Published by the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA) and a recognized journal of professional organizations in several countries, JOSPT strives to offer high-quality research, immediately applicable clinical material, and useful supplemental information on musculoskeletal and sports-related rehabilitation, health, and wellness. Copyright 2011

M  RI for a new episode of low back pain should only be used when a serious underlying condition is suspected, if symptoms of numbness and weakness in the leg are progressing, and/or the results of the imaging scan are likely to change your immediate treatment options.  Your medical provider, such as your physical therapist, can and will perform a thorough examination to determine if a referral for imaging is warranted. However, you should feel comfortable asking your healthcare provider why he or she is recommending an imaging study and how the results of this test will change your medical care.  Physical therapy is safe and recommended for the treatment of low back pain. In most cases of low back pain, it is not necessary to have an MRI before starting treatment. Beginning physical therapy in a timely fashion can potentially speed up your healing as well as your return to full activity. For this and more topics, visit JOSPT Perspectives for Patients online at www.jospt.org.

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