[
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
L
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
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 patient’s
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-
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.
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 Association’s 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
I
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
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[
TABLE
clinical commentary
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
Consider EMG/NCV
INAPPROPRIATE USE OF
LUMBAR SPINE IMAGING:
HARMFUL EFFECTS
Screening for Red Flags
Possible Cause/Key Features on Physical
Examination History
Imaging
Additional Studies
Cancer
History of cancer with new onset of LBP
Unexplained weight loss, failure to improve after
MRI
Lumbosacral plain radiography ESR
1 mo, age over 50 y
Multiple risk factors present
Plain radiography or MRI
Vertebral infection
Fever, intravenous drug use, recent infection
MRI
ESR and/or CRP
MRI
None
Cauda equina syndrome
Urinary retention, motor deficits at multiple levels,
fecal inontinence, saddle anesthesia
Vertebral compression fracture
History of osteoporosis, use of corticosteroids, older
Lumbosacral plain radiography None
age
Anklylosing spondylitis
Morning stiffness, improvement with exercise, alternating buttock pain, awakening due to back pain
Anterior-posterior pelvis plain
radiography
during the second part of the night, younger age
Severe/progressive neurological deficits
Progressive motor weakness
MRI
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
D
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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A
1800
1420
Lumbar MRIs, Thousands
1500
1200
900
600
300
349
0
1994
1996
1998
2000
2002
2004
B
70
61.1
60
Fusions per 100 000
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 Veteran’s 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
50
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 100 000 to
1 in 10 000 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-
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[
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
I
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 patient’s 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 good—for
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 patient’s 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.
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[
clinical commentary
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.
POTENTIAL PATHWAYS
TO LOWER IMAGING: THE
VIRGINIA MASON EXAMPLE
W
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
]
Old Approach
Average cost, $2100-$2200
New Approach
Average cost, $900-$1000
The initial meeting might not
happen for up to a month,
and then there is no set
procedure for treatment
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.
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 Mason’s 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
W
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 patient’s function and disability. Future research should continue to explore
clinical pathways that can reduce inappropriate imaging, decrease costs, and
improve patient outcomes. t
REFERENCES
1. A
mato E, Lizio D, Settineri N, Di Pasquale A,
Salamone I, Pandolfo I. A method to evaluate
the dose increase in CT with iodinated contrast
medium. Med Phys. 2010;37:4249-4256.
2. American College of Radiology. ACR Appropriateness Criteria. Available at: http://
www.acr.org/SecondaryMainMenuCategories/
quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/lowbackpainDoc7.aspx.
Accessed September 29, 2011.
3. American Physical Therapy Association.
APTA Vision Statement for Physical Therapy
2020. Available at: http://www.apta.org/
AM/Template.cfm?Section=Vision_20201&T
emplate=/TaggedPage/TaggedPageDisplay.
cfm&TPLID=285&ContentID=32061. Accessed
August 7, 2011.
4. Ash LM, Modic MT, Obuchowski NA, Ross JS,
Brant-Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient outcomes
in acute radiculopathy and low back pain. AJNR
Am J Neuroradiol. 2008;29:1098-1103. http://
dx.doi.org/10.3174/ajnr.A0999
5. Berrington de Gonzalez A, Mahesh M, Kim K, et
al. Projected cancer risks from computed tomographic scans performed in the United States in
2007. Arch Intern Med. 2009;169:2071-2077.
6. B
oden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans
of the lumbar spine in asymptomatic subjects. A
prospective investigation. J Bone Joint Surg Am.
1990;72:403-408.
7. Brenner DJ, Hall EJ. Computed tomography-an increasing source of radiation exposure. N
Engl J Med. 2007;357:2277-2284. http://dx.doi.
org/10.1056/NEJMra072149
8. Breslau J, Seidenwurm D. Socioeconomic aspects of spinal imaging: impact of radiological
diagnosis on lumbar spine-related disability. Top
Magn Reson Imaging. 2000;11:218-223.
9. Carragee E, Alamin T, Cheng I, Franklin T, van
den Haak E, Hurwitz E. Are first-time episodes
of serious LBP associated with new MRI findings? Spine J. 2006;6:624-635. http://dx.doi.
org/10.1016/j.spinee.2006.03.005
10. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet.
2009;373:463-472. http://dx.doi.org/10.1016/
S0140-6736(09)60172-0
11. Chou R, Qaseem A, Owens DK, Shekelle P.
Diagnostic imaging for low back pain: advice
for high-value health care from the American College of Physicians. Ann Intern Med.
2011;154:181-189.
12. Chou R, Qaseem A, Snow V, et al. Diagnosis
and treatment of low back pain: a joint clinical
practice guideline from the American College of
Physicians and the American Pain Society. Ann
Intern Med. 2007;147:478-491.
13. Crowell MS, Gill NW. Medical screening and
evacuation: cauda equina syndrome in a combat
zone. J Orthop Sports Phys Ther. 2009;39:541549. http://dx.doi.org/10.2519/jospt.2009.2999
14. Dagfinrud H, Kvien TK, Hagen KB. The Cochrane review of physiotherapy interventions
for ankylosing spondylitis. J Rheumatol.
2005;32:1899-1906.
15. Davis PC, Wippold FJ, 2nd, Brunberg JA, et al.
ACR Appropriateness Criteria on low back pain.
J Am Coll Radiol. 2009;6:401-407. http://dx.doi.
org/10.1016/j.jacr.2009.02.008
16. Delitto A, Erhard RE, Bowling RW. A treatmentbased classification approach to low back
syndrome: identifying and staging patients for
conservative treatment. Phys Ther. 1995;75:470485; discussion 485-479.
17. Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol
M, Mulley AG, Jr. Involving patients in clinical decisions: impact of an interactive video
program on use of back surgery. Med Care.
2000;38:959-969.
18. Deyo RA, Diehl AK. Cancer as a cause of
back pain: frequency, clinical presentation,
and diagnostic strategies. J Gen Intern Med.
1988;3:230-238.
19. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI.
United States trends in lumbar fusion surgery
for degenerative conditions. Spine (Phila Pa
1976). 2005;30:1441-1445; discussion 1446-1447.
20. Deyo RA, Mirza SK, Martin BI. Back pain
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
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. Overtreating 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 primary 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. Interventions 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. Psychosocial 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, Robinson 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 utilization 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.
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 | 845
41-11 Flynn.indd 845
10/19/2011 5:25:43 PM
[
clinical commentary
34. H
enschke N, Maher CG, Refshauge KM.
Screening for malignancy in low back pain
patients: a systematic review. Eur Spine J.
2007;16:1673-1679. http://dx.doi.org/10.1007/
s00586-007-0412-0
35. Jarvik JG, Deyo RA. Diagnostic evaluation of low
back pain with emphasis on imaging. Ann Intern
Med. 2002;137:586-597.
36. Jarvik JG, Hollingworth W, Heagerty PJ, Haynor
DR, Boyko EJ, Deyo RA. Three-year incidence
of low back pain in an initially asymptomatic
cohort: clinical and imaging risk factors. Spine
(Phila Pa 1976). 2005;30:1541-1548; discussion
1549.
37. Jarvik JG, Hollingworth W, Martin B, et al. Rapid
magnetic resonance imaging vs radiographs for
patients with low back pain: a randomized controlled trial. JAMA. 2003;289:2810-2818. http://
dx.doi.org/10.1001/jama.289.21.2810
38. Joines JD, McNutt RA, Carey TS, Deyo RA,
Rouhani R. Finding cancer in primary care
outpatients with low back pain: a comparison
of diagnostic strategies. J Gen Intern Med.
2001;16:14-23.
39. Kendrick D, Fielding K, Bentley E, Kerslake R,
Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low
back pain: randomised controlled trial. BMJ.
2001;322:400-405.
40. Leeuw M, Goossens ME, Linton SJ, Crombez
G, Boersma K, Vlaeyen JW. The fear-avoidance
model of musculoskeletal pain: current
state of scientific evidence. J Behav Med.
2007;30:77-94. http://dx.doi.org/10.1007/
s10865-006-9085-0
41. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from
primary care clinics at an academic medical
center: how critical is the need for improved decision support? J Am Coll Radiol. 2010;7:192-197.
http://dx.doi.org/10.1016/j.jacr.2009.11.010
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. O’Laughlin 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
]
51.
52.
53.
54.
55.
56.
57.
58.
general practice guidelines on low back pain
a qualitative study. Spine (Phila Pa 1976).
2001;26:E348-353.
Suarez-Almazor ME, Belseck E, Russell AS,
Mackel JV. Use of lumbar radiographs for the
early diagnosis of low back pain. Proposed
guidelines would increase utilization. JAMA.
1997;277:1782-1786.
Underwood MR, Dawes P. Inflammatory
back pain in primary care. Br J Rheumatol.
1995;34:1074-1077.
United States Department of the Army. Nonphysician Health Care Providers, AR 40-48.
Washington, DC: United States Department of
the Army; 1992.
Verrilli D, Welch HG. The impact of diagnostic
testing on therapeutic interventions. JAMA.
1996;275:1189-1191.
Waddell G. The Back Pain Revolution. 2nd ed.
New York, NY: Churchill-Livingstone; 2004.
Weinstein J, Birkmeyer J. The Dartmouth Atlas
of Musculoskeletal Heatlh Care. Chicago, IL:
AHA Press; 2000.
Weinstein JN, Lurie JD, Olson PR, Bronner KK,
Fisher ES. United States’ trends and regional
variations in lumbar spine surgery: 1992-2003.
Spine (Phila Pa 1976). 2006;31:2707-2714.
http://dx.doi.org/10.1097/01.
brs.0000248132.15231.fe
Wennberg J. Tracking Medicine: A Researcher’s
Quest to Understand Health Care. New York, NY:
Oxford University Press; 2010.
@
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846 | november 2011 | volume 41 | number 11 | journal of orthopaedic & sports physical therapy
41-11 Flynn.indd 846
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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
L
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
Examination
Physical therapy
intervention
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.
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 JOSPT’s 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.
journal of orthopaedic & sports physical therapy | volume 41 | number 11 | november 2011 |
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