The Australian Physiotherapy Association: tests, treatments and procedures physiotherapists and consumers should question

1 Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain

Trials have consistently shown that there is no advantage from routine imaging of non-specific low back pain and there are some potential harms. Imaging is instead recommended for cases of low back pain where there is a suspicion of an underlying medically serious disease, like cancer or infection. In people who present to primary care with low back pain, medically serious disease is uncommon. Patients with a higher likelihood of medically serious disease as the cause of their low back pain can be identified by red flags, like a history of cancer. A recent Australian study revealed that most people experiencing acute low back pain expect imaging, believing it will identify the cause of their pain and so is considered a prerequisite for effective care. These views conflict with the available evidence on imaging.

Supporting evidence

Karel YH, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. Eur J Intern Med 2015;26:585-95.
Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015;313:1143-53.
Slade SC, Kent P, Bucknall T, Molloy E, Patel S, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies. BMJ Open 2015;5:e007265.
Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-2094.
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009;373:463-72.
Chou R, Qaseem A, Owens DK and Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med 2011;154:181-9.
Henschke N, Maher C, Refshauge K, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072-80.
Downie A, Williams CM, Henschke N, Hancock MJ, OStelo RWJG, deVet HCW, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f7095.
Hoffmann, T.C., et al., Patients' expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract 2013;14:7.
Webster BS, Choi YS, Bauer AZ, Cifuentes M, Pransky G. The Cascade of Medical Services and Associated Longitudinal Costs Due to Nonadherent Magnetic Resonance Imaging for Low Back Pain Spine 2014;39:1433–1440.
Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013;38:1939-46.
Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res 2014;49:645-65.

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2 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule

Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. The Canadian C-Spine rule identifies patients who can safely be managed without imaging with high sensitivity.

Supporting evidence

Michaleff ZA, Maher CG, Verhagen A, Rebeck T, LIN CC. Accuracy of the Canadian C-Spine Rule and NEXUS for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 2012;184:E867-76.

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3 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules)

Most clinically significant acute ankle injuries can be diagnosed with history, examination, and selective use of plain radiography. The Ottawa Ankle Rules dictate selective use of plain radiography in patients with acute ankle injury is useful in identifying patients who have sustained clinically important fracture, dislocation, and osteochondral injuries. However, acute ligamentous injuries involving the anterior talofibular ligament can be diagnosed clinically and treated symptomatically. When there are persistent symptoms, which raise suspicion of either instability or other internal derangement such as osteochondral injury, MRI can be used if the non-urgent weight bearing x-rays show no abnormality.

Supporting evidence

Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21:384-90.
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003;326:417-19.
Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med 2009;16:277-87.

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4 Don't routinely use incentive spirometry after upper abdominal and cardiac surgery

Postoperative pulmonary complications occur in ~40% of patients undergoing open coronary artery surgery and upper abdominal surgery. A Cochrane review of 592 open coronary artery surgery patients found no significant benefit on pulmonary complication risk of incentive spirometry over no treatment for atelectasis, pneumonia, or length of hospital stay. Another Cochrane review of 1834 upper abdominal surgery patients found no significant benefit on pulmonary complication risk of incentive spirometry over: no treatment, deep breathing exercises, or other physiotherapy. Further research into incentive spirometry could be conducted, particularly in some subgroups such as high-risk patients. However, these 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. Therefore, until evidence of a benefit from incentive spirometry becomes available, it is recommended that it not be routinely used in these surgical populations.

Supporting evidence

Freitas ERFS, Soares BGO, Cardoso JR. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev 2012;9:CD004466.
Nascimento P, Modolo NSP, Guimaraes MMF, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev 2014;2:CD006058.
Mans CM, Reeve JC, Elkins MR. Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis. Clinical Rehabil 2015;29:426-438.
Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother 2007;53:47-52.
Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomised clinical trial. BMJ 1996;312:148.
Haines KJ, Skinner EH, Berney S. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 2013;99:119-125.
Parry SP, Denehy L, Berney. Clinical application of the Melbourne risk prediction tool in a high-risk upper abdominal surgical population: an observational cohort study. Physiotherapy 2014;100:47-53.

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5 Avoid using electrotherapy modalities in the management of patients with low back pain

Although used in clinical practice for many years, current evidence-based clinical practice guidelines do not endorse electrotherapy modalities (such as ultrasound, laser, interferential) in the management of low back pain, due to lack of evidence of effects on clinically relevant outcomes. Instead, patients with (sub)acute low back pain should be reassured of a favourable prognosis, 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.

Supporting evidence

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075-2094.
Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev 2008;4:CD003008.
Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van Tulder MW. Therapeutic ultrasound for chronic low-back pain. Cochrane Database Syst Rev 2014;3:CD009169.
Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev 2008;2:CD005107.
Seco J, Kovacs FM, Urrutia G. The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review. Spine J 2011;11:966-77.
Chou R, Huffman LH, American Pain S, American College of P. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007;147:492-504.
Primary Care Management of Low Back Pain. August 2014 update Intermountain Health Care https://intermountainhealthcare.org/ext/Dcmnt?ncid=522579081.
The Norwegian Back Pain Network- The communication unit. Acute low back pain. Interdisciplinary clinical guidelines. Oslo, 2002:The Norwegian Back Pain Network.

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6 Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder

Adhesive capsulitis (also termed frozen shoulder) is a condition characterised by spontaneous onset of pain, progressive restriction of movement of the shoulder and disability that restricts activities of daily living, work and leisure. Most studies indicate that it is a self-limiting condition lasting up to two to three years, although 40% people may experience clinically detectable restriction of movement and disability beyond this time point without significant pain. Well-designed randomised trials have not demonstrated any worthwhile clinical benefits from ongoing physiotherapy beyond the benefits of a simple home exercise program.

Supporting evidence

Carette, S., H. Moffet, et al.. "Intra-articular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial." Arthritis & Rheumatism 2003;48:829-838.
Buchbinder R, Youd JM, Green S, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis & Rheumatism 2007;57:1027-37.
Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder), Cochrane Database Syst Rev 2014;8:CD011275.

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