Australian Rheumatology Association
Recommendations from the Australian Rheumatology Association on arthroscopy, ANA testing, imaging, ultrasound and anti-dsDNA antibodies. The ARA supports and educates members and other practitioners in the musculoskeletal field to enable provision of best possible management for patients. It fosters excellence in the diagnosis and management of musculoskeletal and inflammatory conditions through training, professional development, research and advocacy.
Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
Most episodes of low back pain (~90%) do not require imaging. Imaging may identify irrelevant incidental findings and increase the risk of exposure to unnecessary, and sometimes invasive treatment, in addition to increasing costs. For patients with low back pain and no suggestion of serious underlying conditions there are no significant differences in pain or disability outcomes between immediate imaging as compared with usual care without imaging.
- Graves JM, Fulton-Kehoe D, Martin DP, et al. Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation. Spine 2012; 37:1708-18.
- 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.
- Suri P, Boyko EJ, Goldberg J, et al. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskel Dis 2014, 15:152.
- Webster BS, Bauer AZ, Choi Y, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013; 38:1939-46.
An ARA Evolve working group comprising 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients.
A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare.
Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.
- 1 Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
- 2 Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
- 3 Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
- 4 Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
- 5 Do not order anti-double stranded (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high.