Download (Non) Cutting Edge Interventions

Medical Necessity Desired
David Collipp, M.D.
NewSouth NeuroSpine (NS)2
MASI Conference
Thursday February 26, 2015
Embassy Suites, Ridgeland, MS
Overview
 When to order imaging?
 When to use opiates?
 Who needs injections?
 Who needs surgery?
 Therapies?
 Modalities?
 DME?
 RTW?
Bone and
Joint Decade
Taskforce as an initiative of the
U.N. and the WHO with
publications in Spine and Spine
Journal in 2008. This Task Force
included literature review from
1980-2006 with 31,878 citations.
This study included evaluation of
epidemiology, risk factors
(modifiable and nonmodifiable), outcomes and
treatments.
IMAGING
Increasing Use of Imaging for
Low Back Pain
307% increase
in 12 years
Deyo RA et al. J Am Board Fam Med 2009; 22: 62-8
Prevalence: Specific Diagnoses
Rough estimates from primary care:
Compression fracture
4% (or less)
Spondylolisthesis
3%
Malignant neoplasm
0.7% (or less)
Ankylosing spondylitis
0.3%
Spinal infection
0.1%
Spinal Stenosis
??
Surgically important disc herniation
Total Specific Diagnoses: ~10%
2%
“Normal” MRI Results in 67 Subjects
Age
Under 60 Over 60
Herniated disc
22%
36%
Spinal Stenosis
1%
21%
Bulging disc
54%
79%
Degenerated disc
46%
93%
Boden et al, JBJS, 1990
Imaging Hazards
A diagnosis based on MRI, in the
absence of objective clinical
findings, may not be the cause of a
patient’s pain, and an attempt at
operative correction could be the
first step toward disaster.
Boden et al, JBJS, 1990
Impact of Imaging on Outcomes: Testing a
Diagnostic Test
6 RCTs, 1804 patients, no red flags
4 trials plain x-ray, 2 of MR or CT
No advantage of imaging in short or long term (up to 1 year) for:
-pain
-mental health
-function
-satisfaction with care
-quality of life
Results not affected by trial quality, imaging modality, duration of LBP
Chou R, Fu R, Carrino JA, Deyo RA. Lancet 2009; 373: 463
Could imaging do harm?
2 RCTs
1. British RCT: 421 pts, >6 weeks of LBP
After 3 months, those who received x-rays:
-had worse pain
-lower overall self-reported health
-but…were more satisfied with care
2. 246 pts with lumbar MR, randomized to receive results or not
Self-rated general health improved significantly more in patients
who were blind to the MR results.
Kendrick D, et al. BMJ 2001; 322: 400
Ash LM et al. Am J Neuroradiol 2008; 29: 10981103
“Cascade Effects” of early lumbar MRI?
1. Workers Comp, n=3,264, 22% early MRI
 Low-risk patients who received MRI were several times
more likely to receive injections, and surgery.
 These were more associated with early MR than clinical
severity or demographic indicators.
Webster BS et al. J Occup Env Med 2010; 52: 900
2. 380 pts randomized to plain x-ray vs. MRI
 2.5x more surgery in MR group (p=.09)
 Equivalent pain & function at 1 year
 MR group more reassured
Jarvik J, Deyo R et al. JAMA 2003; 289: 2810
2007 and 2011 ACP/APS Back Pain
Guidelines
 No routine imaging, dx tests for non-specific LBP.
 Image if major Ca risks; progressive neuro deficit,
cauda equina, new fever or injection drug use.
 Image after Rx trial if risks for comp fx, ankylosing
spondy, stenosis, or minor risks for Cancer.
 No discography
Chou R et al. Ann Intern Med 2007; 147: 478.
Chou R et al. Ann Intern Med 2011; 154: 181.
The Doctor’s Dilemma: How to be patientcentered and evidence-based.
 Physicians are often concerned about patient
satisfaction and medicolegal risks.
 Strong pressure contrary to evidence; pts seek
mechanical explanations. Labeling, costs, cascade
effects don’t resonate.
 Survey: 36% of physicians would order MR for 1st
episode of acute LBP (2 days) that began in work
around house if pt. insistent, even after explaining test
unnecessary.
Campbell. Ann Intern Med 2007; 147: 795
Addressing patient demand?
 Satisfaction ≠ better health--implications for
performance measures.
 Redouble patient education--some evidence that
satisfaction can be maintained.
 Imaging itself teaches patients what to expect--in one
RCT obtaining x-rays raised the expectation they should
always be done.
 Quality of care is defined in part by avoiding overuse—
physicians must teach that more is not always better.
Deyo RA et al. Arch Intern Med 1987; 147: 141-45
Treatment
Gotta Start Somewhere
Opioids
Diagnosis
-Soft Tissue (first 48-72 hours)
-Neurologic (role)
-Orthopedic (1 week to 3 months)
Timing
-acute v chronic
Precautions
-drug interactions
-medical conditions
-addiction
-diversion
-impact on function
Tool
-History and Physical
-Phone
-https://rpt.pmp.relayhealth.com/MS
-Old records
-UDS
Opioids
From 1997 to 2004 there
was a 556% increase in
sales of Oxycodone, a 500%
increase in therapeutic
grams of Oxycodone used,
and a 568% increase in the
non-medical use of
sustained-release
Oxycodone, a 229%
increase in opioid-related
deaths (without heroin or
cocaine) an increase from
1942 (1999) to 4451 (2002)
deaths.
Drug Enforcement Agency (DEA)
Automated Reports and Consolidated
Orders System
Increase in Expenditures,
1997-2006: 660%
Due to both volume and price
$246 Million
$1.9 Billion
Martin BI, Deyo RA et al.
Spine 2009; 34: 2077
Opioids
Retail sales noted an increase
from 1997 to 2007 in
Methadone (1293%),
Oxycodone (866%), Fentanyl
(525%), hydromorphone
(319%), and morphine (222%).
Average per person sale
increased from 1997 (74mg) to
2007 (369mg). The U.S. has
4.6% of the world’s population
and consumes about 80% of
the world’s opioid supply, and
99% of the hydrocodone, as
well as 2/3’s of the world’s
illegal drugs.
Manchikanti L, et al., Therapeutic use,
abuse and nonmedical use of opioids: A
ten-year perspective, Pain Physician, 2010;
13(5):401-35.
Opioids
Opioid misuse in workers’
compensation settings has
been linked to death, and
higher rates of misuse are
noted in unemployed
patients.
Epidemiological Trends in Abuse and
Misuse of Prescriptions Opioids. Spiller, H,
et. al., 2009, J Addict Dis, Vol. 28, pp. 130-36
Opioids
Long Term Opiate Use for
Chronic, Non-malignant
Pain.
-Inadequate Pain Relief
-Poorer quality of Life
-Long-term
unemployment
-High levels of medical
care seeking
Eriksen J, et al., Critical issues on opioids in
chronic non-malignant pain: An
epidemiological study, Pain, 2006; 125:172-9
Opioids
Reduce likelihood of
recovery from chronic pain
(4x)
Higher risk of death 1.67:1
Poor pain relief (mean 32%
in about 40% of patients)
Poor quality of life
Unimproved functional
capacity
52.1% had recovery from
Chronic Intractable Pain
(not from opioids).
Sjøgren P, et al., A population-based cohort
study on chronic pain: The role of opioids,
Clinical Journal of Pain, 2010;26(9):763-9
Opioids
Individuals with high-dose
opioid therapy after workrelated injuries had poorer
outcomes in terms of RTW,
work retention, medical
utilization and long-term
disability status compared
with those who did not opt
for opioids.
Kidner CL, et al., Higher opioid doses
predict poorer functional outcome in
patients with chronic disabling occupational
musculoskeletal disorders, JBJS (Am),
2009;91(4):919-27
Opioids
VA Pts receiving high-dose opioids reported
higher pain levels (on meds) than patients
receiving lower doses.
Danish population survey: chronic pain
patients using opioids reported lower Quality
of life (SF-36), more severe pain than those
not receiving opioids.
Morasco B,…Deyo RA, et al. Pain 2010; 151: 625. Eriksen
J, et al. Pain 2006; 125: 172.
Opioid prescribing for low back pain
 Useful for severe acute pain; time-limited use or
nighttime use with NSAIDs during day.
 Generally switch within 2 weeks of use; prepare patient.
 Avoid >100mg/day morphine equivalents.
 Avoid co-prescriptions of BZDs and Soma with opiates.
 Long-term use: screen carefully for hx of substance
abuse, mental illness, depression; informed consent .
 APS Guide: option for severe disabling LBP; carefully
consider risk:benefit; consider alternatives if no response
to short course.
 Focus on Function.
Injections
Efficacy of Epidural Steroid and
Facet Injections?
 For sciatica, mixed study results: ½ suggest modest
benefit, ½ suggest no benefit.
 Axial back pain: no evidence of benefit. (58% of injections
not for radiculopathy or HNP.)
 No reduction in surgery rate in 2 RCT’s; surgery rates
highest where injection rates highest.
 Facet injections: RCT’s consistently neg.
 Overall: modest sciatica symptom relief from epidurals,
no change in outcomes.
Suggestions regarding injections
 APS and Am Acad. Neurol. Guidelines: Epidural
steroids for temporary pain relief of persistent lumbar
radiculopathy.
 AAN: ESI--No effect on functional impairment, need for
surgery, or pain relief beyond 3 mos; routine use for
these reasons not recommended.
 Avoid epidurals for back pain; avoid facet joint
injections.
 Insufficient evidence for spinal stenosis.
Trigger Point Injections
Not recommended in
Chronic Low Back
Pain.
May help in acute LBP
when all other
conservative measures
have failed.
“Evidence-informed management of chronic
low back pain with trigger point injections”
Malanga G, et al., Spine Journal, Jan 2008 (8),
issue 1, 243-252
Surgery
Indications for Spine Surgery
 Cauda Equina syndrome: bilateral leg
weakness, difficulty walking, bowel or
bladder dysfunction (usually urinary
retention).
 Progressive neurologic deficit.
 Certain cases of fracture, tumor, and
infection.
Elective surgery
Patient with herniated disc, stenosis or
spondylolisthesis with back and leg pain.
Poor response to conservative Rx.
Hx, exam, imaging all consistent.
Patient understands benefits, risks, of both
surgery and non-operative care.
Back pain alone? Some controversy.
Neurological Recovery in RCT for
Herniated Disc (N=64 w/Paresis)
4 yr: Total recovery
dorsiflexion
Total recovery
plantar flexion
10 yr: Recovery all
weakness
No
Surgery Surgery
44%
43%
56%
75%
84%
84%
Weber H. Spine 1983; 8: 131
HNP: Surgery v Non-surgery
Non-surgical
Surgical
Peul WC et al. N Engl J Med
2007;
356:J2245
Peul WC et
al. N Engl
Med 2007; 356: 2245
Surgical Outcomes
“This systematic review of the
literature revealed that
patients treated under
compensation schemes or
undergoing litigation
consistently have worse
outcomes after surgery than
non-compensated patients.
Of the 211 studies reviewed, 175
reported a worse outcome in
compensated patients.
Overall, compensated patients
have more than 3 times the
odds of an unsatisfactory
outcome compared with noncompensated patients.”
Harris, Mulford, Solomon, Gelder & Young,
JAMA, April 6, 2005-Vol 293, No. 13,
“Association Between Compensation Status
and Outcome After Surgery”
Physical therapy
and friends
Physical Therapy
Exercise is a proven
treatment for back and
neck pain from injury and
degenerative disease.
Sedentary overweight and
obese adults can be advised
to initiate and maintain an
exercise program. Only 7%
had injury attributable to
exercise alone.
Janney CA and Jakicic JM, The influence of
exercise ad MBI on injuries and illnesses in
overweight and obese individuals: a RCT,
International Journal of Behavioral
Nutrition and Physical Activity; Jan 6, 2010
Physical Therapy
Exercise and supervised exercise
includes aggressive stretching
and strengthening work.
Therapy for targeted muscles or
muscle groups and can include
flexion or extension bias based
upon patient’s clinical findings.
PT causes muscular
discomfort during and
after the exercises,
particularly with some
delayed onset muscle
soreness.
Physical Therapy
There is no evidence that
any particular form of
exercise (walking, running,
swimming, yoga, Pilates) is
superior to the resumption
of normal activity in acute
back pain.
Hendrick P, et al., The effectiveness of
walking as an intervention for low back
pain: a systematic review, European Spine
Journal, 2010
Traction
300 pounds of manual
traction results in a 1cm
cumulative interspace
distance increase.
Cyriax JH. Textbook of Orthopedic
medicine: diagnosis of soft tissue lesions.
8th Ed. London: alliere Tindall, 1982
Patient selection best
limited to DJD/DDD and
disc herniations with
mechanical root irritation.
Gains should be greater
than 2mm.
Modalities
Heat
Ice
Short-wave Diathermy
TENS
Ultrasound
No Evidence for use in Chronic
Low Back Pain.
Use as adjunct to tolerate therapy
in acute injury accepted.
“Evidence-informed management of
chronic low back pain with
transcutaneous electrical nerve
stimulation, interferential current,
electrical muscle stimulation,
ultrasound, and thermotherapy.”
Poitras S, Brusseau L, Spine Journal, Jan
2008; (8)issue 1, 226-33
TENS
Short-term use has
documented benefit, but
long-term use has no
statistical benefit.
“Evidence-informed management of
chronic low back pain with
transcutaneous electrical nerve
stimulation, interferential current,
electrical muscle stimulation,
ultrasound, and thermotherapy.”
Poitras S, Brusseau L, Spine Journal, Jan
2008; (8)issue 1, 226-33
Cognitive Behavioral Therapy
Helpful for acute
and chronic LBP,
and recommended
to be used with a
multidisciplinary
approach.
“Evidence-informed management of chronic
low back pain with cognitive behavioral
therapy” Gatchel R, et al., Spine Journal, Jan
2008 (8), issue 1, 40-44
Back school,
Brief Education,
Fear-avoidance
training.
Brief Education is
superior to CBT for
moderate
kinesiophobia and
pain, and current
recommendations are
to have brief
education as part of a
PT program.
“Evidence-informed management of
chronic low back pain with back
schools, brief education, and fearavoidance training” Brox, JI, et al.,
Spine Journal Jan 2008 (8), issue 1, 2839
Massage
Recommended effective
for chronic LBP, and
acupressure may be
better than massage.
“Evidence-informed management of
chronic low back pain with massage”
Imamura M. et al., Spine Journal, Jan
2008 (8), issue 1, 121-133
Acupuncture
Not recommended for
acute or chronic LBP.
Poor studies overall, and
very short term relief.
“Evidence-informed management of
chronic low back pain with needle
acupuncture” Ammendolia C, et al.,
Spine Journal Jan 2008 (8), issue 1, 160-172
Home exercise program,
Smoking cessation,
Weight loss.
HEP has moderate
evidence to be helpful
for CLBP, whereas
smoking cessation and
weight loss are of no
statistical benefit.
“Evidence-informed management of
chronic low back pain with physical
activity, smoking cessation, and weight
loss” Wai, EK, et al., Spine Journal, Jan
2008 (8), issue 1, 195-202
Spinal Manipulative
Therapy (SMT)
Mobilization
SMT and mobilization at
least equal to PT for
outcomes in acute and
chronic LBP.
“Evidence-informed management of
chronic low back pain with spinal
manipulation and mobilization”
Bronfort, G, et al., Spine Journal Jan 2008
(8), issue 1, 213-225
DME
Assistive devices (e.g.
Canes, walkers,
hemiwalkers, quad canes,
Lofstrand crutches, etc.)
and orthotics (e.g. TLSO,
LSO, Chairback etc.)
should be avoided unless
being prescribed for some
other condition or
neurologic damage related
to the spine injury.
Increase injury possibility,
and decrease prescribed
treatment effectiveness.
Return to work
Return to Work
Canadian
Medical
Association
Policy Summary
“The Physician’s Role in Helping
Patients Return to Work After
Illness or Injury”
CMAJ 1997; 156 (5): 6, 80 A-F
“Prolonged absence from one’s
normal roles, including
absence from the workplace,
is detrimental to a person’s
mental, physical, and social
well being. Physicians should
therefore encourage a
patient’s return to function
and work as soon as possible.”
RTW
2000 Ontario, Canada
Workplace Safety and
Insurance Board (WSIB)
http://www.wsib.on.ca/wsi
b/wsibsite.nsf/LookupFiles
/DownloadableFilePhysicia
nsRTWGuide/$File/RTWG
P.pdf
“Prolonged absence from
one’s normal role is
detrimental to physical,
mental, and social well
being. Long term
unemployment postinjury is itself a health
problem.”
RTW
August 2004
UK Department
of Work and
Pensions
Medical evidence for Statutory
Sick Pay. Statutory Maternity
Pay and Social Security
Incapacity Benefit purposes. A
Guide for Registered Medical
Practitioners.
http://www.dwp.gov.uk/medica
l/medicalib204/ib204june04/ib204.pdf
“As a certifying doctor you will
need to consider and manage
your patient’s expectations in
relation to their ability to
continue working. In summary,
you should always bear in mind
that a patient may not be well
served in the longer term by
medical advice to refrain
from work, if more appropriate
clinical management would
allow them to stay in work or
return to work.”
RTW
AMA Policy and
Directives 2004
Adopted June 2004
http://www.amaassn.org/ama/pub/article/print/20
36-8668.html assessed 06/26/04
2. The AMA encourages
physicians everywhere to
advise their patients to
return to work at the
earliest date compatible
with health and safety and
recognizes that physicians
can, through their care,
facilitate patients’ return to
work. (Policy)
RTW
Joint statement by:
Faculty of Occupational
Medicine
Royal College of General
Practitioners
Society of Occupational
Medicine
UK 2005
http://www.facoccmed.ac.uk/libra
ry/docs/conf_haw.pdf
“ ‘Worklessness’ (being
unemployed or economically
inactive and in receipt of
working age benefits) causes
poor health and health
inequality, and this effect is
still seen after adjustment for
social class, poverty, age, and
pre-existing morbidity.”
RTW
Joint statement by:
Faculty of Occupational
Medicine
Royal College of General
Practitioners
Society of Occupational
Medicine
UK 2005
http://www.facoccmed.ac.uk/libra
ry/docs/conf_haw.pdf
-“People who are out of work
experience poorer mental health
…”
-“Anxiety and depression are two
to three times more common …”
-“Being out of work can lead to
increased smoking,
consumption of alcohol, use of
illicit drugs, and risk taking
sexual behavior.”
-“… worklessness leads to
increased mortality rates.”
RTW
Joint statement by:
Faculty of Occupational
Medicine
Royal College of General
Practitioners
Society of Occupational
Medicine
UK 2005
http://www.facoccmed.ac.uk/libra
ry/docs/conf_haw.pdf
“The negative
effects of
unemployment
are reversible on
re-entry to work.”
RTW
Unemployment
is detrimental to
your health.
The health consequences of
unemployment: the evidence.
Mathers, Schofield, Med J Aust
1998; 168 (4): 178-182
“…longitudinal studies with a range
of designs provide reasonably good
evidence that unemployment itself
is detrimental to health and has an
impact on health outcomes –
increasing mortality rates, causing
physical and mental ill-health, and
greater use of health services.”
RTW
“Effects of unemployment on
mortality were more pronounced
with increasing duration of
unemployment.”
“Conclusion: The relative excess
mortality of unemployed men in
Finland cannot be explained by
demographic, social, and health
variables preceding
unemployment. Unemployment
therefore seems to have an
independent causal effect on
male mortality.”
Unemployment and Mortality among
Finnish men 1981-85, Martikainen P,
BMJ 1990; 301 Sep: 407-411
Controlled for background variables affecting
mortality.
Total Mortality:
unemployed have a (relative risk)
RR of 1.93 (95% CI = 1.82-2.05)
Accidental and violent death:
RR 2.51 (2.28-2.76)
Circulatory Diseases:
RR 1.54 (1.40-1.70)
RTW
-Men with unemployment or early retirement 2x more likely to die in the
next 5.5 years (BMJ 1994)
-Unemployment independently related to mortality (Scand J Prim Health
Care 1996)
-Unemployed have increased mortality ratio (Lancet 1996)
-Unemployed have 25% increased cancer mortality (IARC Sci Publ 1997)
-Unemployment related to psychiatric symptoms and death (Scand J
Work Environ Health 1997)
-Increased cardiovascular mortality in US, UK and Scand (Acta Physiol
Scand 1997)
-Unemployment significantly related to suicide (J Stud Alcoh0l 1998)
-Premature mortality (Am J Public Health 1999)
-Related to Mortality (Occup Environ Med 2001 {Twin Study})
-Increased death risk by 50% (J Health Economics 2003)
-Increased CVA and MI (Am J Ind Med 2004)
Conclusions
 MRI for radicular findings or trauma that could
cause fracture/tear. Or 1 month of failed
conservative management (new diagnosis?).
 Report degenerative changes as such.
 Minimal Narcotics and brief use.
 ESI for radiculopathy, avoid most facet joint
injections.
 Judicious use of Trigger Point injections.
 Rarely surgical; most surgery truly elective.
Conclusions
 Avoid excessive modalities (adjunctive).
 Avoid Acupuncture (pending research).
 Avoid canes, walkers, bracing etc.
 Avoid focusing on weight loss and smoking
cessation.
 Avoid HEP as stand-alone treatment.
Conclusions
 Use minimal narcotics, carefully, briefly.
 Use therapy to increase activity level, noting it will be







uncomfortable in both acute and chronic patients.
Use brief Education-especially during treatment.
May use Cognitive Behavioral Therapy.
May use Traction for mechanical compression and
DJD.
Use NSAIDs.
May use Mobilization and Manipulation.
May use TENS (short term).
May use Massage/MFR for CLBP.
Conclusions
 Keep your patients at work as much as
possible.
The End: Thank You
65
Thank You