YOU ARE THE BEST OPTION FOR LOW BACK PAIN

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1 YOU ARE THE BEST OPTION FOR LOW BACK PAIN Amy Garrigues PT, DPT Orthopaedic Clinical Specialist Fellow, American Academy of Orthopaedic and Manual Physical Therapists LBP in past 3 months 25% 307% 220% Increase in imaging Increase in spinal fusion surgery $ BILLION DOLLARS 20 Lumbar Fusion U.S. Foreign Aid Cancer Research (Breast, Lung, Prostrate) Cochrane Collaboration: the benefit of opiods in clinical practice for the longterm management of chronic LBP remains questionable. or otherwise used without express written permission of the authors. 1

2 Guidelines YET.. STRONG RECCOMENDATION; MODERATE-QUALITY EVIDENCE 108% INCREASE In Rx 423% INCREASE in cost Risks Chronic LBP Tricyclic Antidepressants Moderate short-term pain relief GI Complaints Overdose Hyperalgesia Hypogonadism Organ damage Death Pain medications don t fix the problem, they may help in the short term, but long term use leads to higher pain levels and poorer quality of life. or otherwise used without express written permission of the authors. 2

3 Guidelines What s Happening Here? STRONG RECCOMENDATION; MODERATE-QUALITY EVIDENCE Which of these is predictive of LBP? Physical Imaging Findings (MRI or Radiographs) 1. Bulging discs without herniation or root contact 2. Bulging discs without herniation but with root contact 3. Herniated / Prolapsed discs 4. Degenerative disk disease 5. Facet arthropathy 6. End plate changes/schmorl s nodes 7. Foraminal or canal stenosis Psychosocial Findings 1. History of depression 2. History of occupational-related LBP 3. Fearful beliefs about work as reported through a survey YET. Up 307% since 1996 Slide Courtesy of Tim Flynn Projected # of Future Cancers Due to Lumbar CT Scans Performed in the U.S. in 2007 Outcomes # of Scans Female Cancers 2.2 Million Male Cancers Total The Magnet is not Therapeutic! -- Tim Flynn PT, PhD Arch Intern Med 2009;169: Slide or otherwise used without express written permission of the authors. 3

4 Risks. Lumbar Spine CT scans result in increased cancer risk (Barringon de Gonzalez et al. 2009) MRIs lead to higher rates of surgical intervention (Jarvik et al. 2003) J Am Board Fam Med 2009;22:62 68 Slide Slide Findings on MRI are only important if they back up findings on physical exam. Furthermore, they are often completely unrelated to outcome other than predicting surgery. MRI s are indicated only when there is a medical history (cancer) or progressive neurological deficit cancers per year are attributed to undergoing CT scan. Guidelines or otherwise used without express written permission of the authors. 4

5 Inpatient Utilization Lumbar Fusions increased 220% from Total Expenditures ($ billion) Percent of all Treated Spine Patients Martin, et al SPINE. 34: In Your Backyard Re-operation Rates over 4 years: Decompression ~18% Spinal Fusion ~25% Major complication rates for elderly patients Neurologic injury occurs in 1 5% of patients. Infection occurs in 1 8%. Top Spine Surgeons Reap Royalties, Medicare Bounty, WSJ, Dec. 20, 2010 Martin et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 22(3) OUTCOME Simple Fusion Complex Fusion Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study. Pain. 2006;122: Hospital Cardiac Event or Stroke Death within 30 days D/C to Nursing Home Hospital Charges $59,000 $81,000 or otherwise used without express written permission of the authors. 5

6 Improving Decision-Making in Low Back Pain: How to Target the Right Treatment at the Surgery really is a last resort and indicated only with progressive neurological signs and declining function. Surgery has not been found to dramatically reduce central low back pain. WHO ARE THE BEST PRACTITIONERS TO ADDRESS THE LOW BACK PAIN EPIDEMIC? The GOOD news is, even though your MRI results aren t perfect you are a great candidate for conservative rehabilitation. Physical Therapists 1. Musculoskeletal Specialists 2. Direct Access 3. Positive Meaningful Functional Outcomes supported by evidence REFERENCES REFERENCES Fritz, J.M. et al., Is there a subgroup of patients with low back pain Brennan, G.P. et al., Identifying subgroups of patients with acute/subacute nonspecific low back pain: results of a randomized clinical trial. Spine, 31(6), p.623. Chou, R. & Huffman, L.H., Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of internal medicine, 147(7), p.505. Chou, R. 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. Annals of internal medicine, 147(7), p.478. Deyo, R.A. et al., United States trends in lumbar fusion surgery for degenerative conditions. Spine, 30(12), p Deyo, R.A., Mirza, S.K. & Martin, B.I., Back pain prevalence and visit rates: estimates from US national surveys, Spine, 31(23), p Deyo, R.A. et al., Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA: the journal of the American Medical Association, 303(13), p Deyo, R.A. et al., Overtreating Chronic Back Pain: Time to Back Off? The Journal of the American Board of Family Medicine, 22, pp likely to benefit from mechanical traction?: Results of a randomized clinical trial and subgrouping analysis. Spine, 32(26), p.e793. Martin, B.I. et al., Expenditures and health status among adults with back and neck problems. JAMA: the journal of the American Medical Association, 299(6), p.656. Martin, B.I., Mirza, S.K., Comstock, B.A., Gray, D.T., Kreuter, W. & Deyo, R.A., Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Spine, 32(19), p Martin, B.I., Mirza, S.K., Comstock, B.A., Gray, D.T., Kreuter, W. & Deyo, R.A., Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine, 32(3), p.382. Martin, B.I., Turner, J.A., Mirza, S.K., Lee, M.J., Comstock, B.A. & Deyo, R.A., Trends in health care expenditures, utilization, and health status among US adults with spine problems, Spine, 34(19), p Nguyen, T.H. et al., Long-term Outcomes of Lumbar Fusion Among Workersʼ Compensation Subjects. Spine, p.1. or otherwise used without express written permission of the authors. 6