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Choosing wisely - increasing the value of physiotherapy

Clinical physiotherapist Dr Adrian Traeger
Photo: Clinical physiotherapist Dr Adrian Traeger
Low back pain is one of the most prevalent health conditions in our nation, with about a quarter of all Australians experiencing the condition in any one day.

While the cause of acute low back pain is often benign, and the prevalence of underlying serious causes, including nerve or bone damage, infection or cancer, is very low, many patients are still being routinely sent for diagnostic imaging, such as an X-ray, CT or MRI scan.

A recent Australian study revealed most people experiencing low back pain believe imaging will pinpoint the cause of their pain but trials show there are no benefits, and some potential harms, for routine imaging of low back pain.

Physiotherapists are now being urged to avoid referring patients for imaging for non-specific low back pain, where there are no indicators of a serious cause for the pain.
It’s one of the key recommendations from the Australian Physiotherapy Association (APA) as part of the Choosing Wisely Australia campaign.

Physiotherapy’s peak professional body has outlined six recommendations and one proposed recommendation in a bid to eradicate low-value healthcare services that are often unnecessary and expensive, and also lead to potential harms, such as exposure to radiation.

The recommendations range from urging physiotherapists to avoid imaging for the cervical spine in trauma patients to not using spirometry after upper abdominal and cardiac surgery.

The latest proposed recommendation, now being reviewed, urges physiotherapists not to prescribe massage or electrotherapy, such as ultrasound, laser or transcutaneous electrical nerve stimulation (TENS), for older people experiencing pain from knee or hip osteoarthritis.

Instead, physiotherapists are being encouraged to swap the over-use of imaging, diagnoses and ineffective treatments with more effective patient consultations and physiotherapy treatments.

Clinical physiotherapist Dr Adrian Traeger is a member of the APA Choosing Wisely Panel who is also a Research Fellow at the Sydney School of Public Health, University of Sydney, where he’s conducting research investigating the causes of and solutions to problems of overdiagnosis and overtreatment in modern healthcare systems.

Dr Traeger says evidence suggests most clinicians know imaging for low back pain is not useful but still recommend it in a bid to reassure patients.

In an editorial on low-value healthcare about to be published in the APA’s Journal of Physiotherapy, Dr Traeger states research shows drivers of low-value care include advanced improvements in technology, as well as professional and commercial factors.

Cultural factors also play a part - such as ordering tests as a matter of habit, having a fear of litigation in the event a serious disease is overlooked, and feeling pressured by patients.

“Certainly some patients want a scan or want a test but others just want a good explanation. I think sometimes clinicians wrongly assume that every patient wants a scan without having actually discussed it with them,” he says.

“Unfortunately we know that those tests don’t tell us very much about where the pain is coming from, and they don’t really inform management - so they can’t lead to more specific treatments that will help people recover better.

“In actual fact, they can be harmful. Imaging results can make you worry more because they often detect changes in your spine that are normal for age but might not look that pretty on a scan. That can lead to treatments that target those incidental findings from the scan, and these treatments usually cause more harm than good.

“We know from large scale research that when people with low back pain have scans they tend to feel worse afterwards, they tend to use more healthcare, and that healthcare doesn’t improve their outcome.”

Dr Traeger says physiotherapists can detect the potential risk of more serious causes of low back pain with a thorough consultation.

“A good clinical history, examination, and explanation by the physiotherapist can replace a lot of these tests,” he says.

“If you take a good history and do a good physical examination, and explain to the patient exactly what you think is going on - that has actually been shown in the research to be more reassuring than providing someone with the results of imaging tests.

“That’s why we discourage imaging and we encourage talking about the problem a little bit more.”

The Choosing Wisely campaign, an initiative of NPS MedicineWise, is designed to encourage conversations between health practitioners and their patients about the tests and procedures of low value - that provide patients with little or no benefits and which may even cause harm.

The APA’s six recommendations are the result of a survey of almost 3000 physiotherapists, which were put to the APA’s panel of clinicians and researchers.

The physiotherapy body states the recommendations are not prescriptive - they should be used as a guide to prompt clinicians and consumers to question and discuss what is appropriate care in each individual case.

The recommendations join an evolving list of recommendations for tests, treatments and procedures to question, from a range of colleges and societies representing health practitioners, including nurses, hospital pharmacists, pathologists, radiologists, GPs, surgeons and palliative care specialists.

Dr Traeger says the Sydney School of Public Health, as part of the NHMRC-funded Wiser Healthcare Research Collaboration, is now examining a range of tools that may be able to assist physiotherapists and their patients make wiser choices.

“We are looking at methods that have worked in other health areas, and investigating how we can apply these methods to physiotherapy problems,” he says.

“This involves talking to physiotherapists, GPs, radiologists and the public, and finding out why they use certain tests and treatments.”

Dr Traeger says it’s vital physiotherapists are supported to provide patients with the right care at the right time - to improve health outcomes.

“It’s difficult - there are significant time pressures, patient pressures - physiotherapists treat lots of different conditions and it can be difficult to manage these pressures and stay on top of the current evidence base,” he says.

“We want to develop new ways of helping clinicians engage in discussions about low-value tests and treatments, and replace some of these services with services that have the evidence base. It all seems straightforward but can be hard to do in practice.”

The APA’s Choosing Wisely recommendations:
1. Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
Patients can self-manage an episode of back pain through staying active and using simple pain medicines or a hot pack to relieve their pain. Physiotherapists can provide treatment to relieve the pain and can also educate patients about caring for their back.
2. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule.
The Canadian C-Spine rule identifies patients who can safely be managed without imaging with high sensitivity.
3. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules.
Most clinically significant acute ankle injuries can be diagnosed with history, examination, and selective use of plain radiography.
4. Don't routinely use incentive spirometry after upper abdominal and cardiac surgery.
Cochrane reviews identify a substantial pool of existing evidence that has not demonstrated any benefits of incentive spirometry. Other interventions, such as preoperative inspiratory muscle training do improve postoperative outcomes in these patients, when added to established standard care such as early mobilisation.
5. Avoid using electrotherapy modalities in the management of patients with low back pain.
Instead, patients with (sub)acute low back pain should be reassured, advised to stay active, and be referred for prescribed analgesia if necessary. For chronic low back pain, helpful interventions include short-term use of medication/manipulation/acupuncture, supervised exercise therapy, cognitive behavioural therapy and multidisciplinary treatment.
6. Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder.
Well-designed randomised trials have not demonstrated any worthwhile clinical benefits for ongoing physiotherapy beyond the benefits of a simple home exercise program.
7. Proposed recommendation - Don’t prescribe electrotherapy, such as ultrasound, laser or transcutaneous electrical nerve stimulation (TENS), or massage for an older person with pain due to knee or hip osteoarthritis.
Instead, physiotherapists should collaborate with the patient as part of a multidisciplinary team to prescribe exercise-based intervention in association with other evidence-based managements, such as weight control, use of assistive aids, disease education, self-management and medicines review.
Source: APA.

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

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