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.
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.
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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.
- 1 Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
- 2 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule
- 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).
- 4 Don't routinely use incentive spirometry after upper abdominal and cardiac surgery
- 5 Avoid using electrotherapy modalities in the management of patients with low back pain.
- 6 Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder