The Australian Physiotherapy Association

Recommendations from the Australian Physiotherapy Association on low back pain, clinical decision rules, incentive spirometry & frozen shoulder. The Australian Physiotherapy Association (APA) is the peak body representing the interests of Australian physiotherapists and their patients. The APA is a national organisation with non-autonomous state and territory branches and specialty subgroups. The organisation has more than 19,000 members and over 300 members in volunteer positions on committees or working parties.

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

Date reviewed: 1 March 2016

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.
How this list was made How this list was made

The APA sought nominations from fellows and associates of the Australian College of Physiotherapy, directors of the Physiotherapy Evidence Database, clinical specialist APA members and academic physiotherapists to form an expert panel. The APA invited all members to submit evidence about interventions related to physiotherapy that should be questioned. From members’ submissions and the expert group’s research, the expert group formed a shortlist of 8 recommendations. The expert group then considered the shortlist in terms of the extent of the health problem, usage of the test or intervention, and the evidence that the test or intervention is inappropriate. From this analysis, the expert panel selected five recommendations to put to APA members. In a second round of consultation, the APA received nearly 2500 responses, and almost 900 comments. The expert panel then considered feedback and refined the recommendations. This resulted in the 6 recommendations put forward below, for which there was overwhelming majority support.

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