Low Back Pain Visit Research Articles

A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis

ObjectiveThe purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data. MethodsWe performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators. Visits meeting our history and/or examination and treatment indicators were classified as “high-quality” visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria. ResultsThere were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a “high-quality” visit, while other regression associations were non-significant. ConclusionThis study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

Emergency department presentations and associated hospital admissions for low back pain in Australia.

ObjectiveTo determine factors associated with hospital admissions from ED presentations for low back pain (LBP).MethodsThis was a retrospective analysis of 147 ED centres in New South Wales (NSW), Australia, between 2005 and 2014. Data were accessed from the NSW Emergency Department Data Collection to determine patients who attended ED and whether or not they were admitted to hospital.ResultsThere were 1 388 078 ED visits for LBP across 147 different ED centres between 2005 and 2014. Between 2005 and 2013, hospital admission rates from ED visits for LBP increased annually by 5.1% (95% confidence interval [CI] 3.9–6.4) from 477 per 100 000 in 2005 to 730 per 100 000 in 2013. Patients who were under injured workers' insurance (i.e. workers compensation insurance) had significantly lower odds (odds ratio [OR] 0.42, 95% CI 0.40–0.43) of being admitted to hospital for LBP compared with those not on injured workers' insurance. Patients living in the highest socioeconomic areas were also more likely to be admitted to hospital from an ED visit, compared with those from the lowest socioeconomic areas (OR 1.26, 95% CI 1.24–1.29).ConclusionRates of hospitalisation following attendance to ED for LBP increased annually by 5% between 2005 and 2013. Hospital admission rates were lower among patients from the lowest socioeconomic areas or under injured workers' compensation insurance.

Factors Associated With Repeat Emergency Department Visits for Low Back Pain.

BackgroundLow back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period.MethodologyWe conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months.ResultsA total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028).ConclusionsPatients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

Use of healthcare resources in patients with low back pain and comorbid depression or anxiety

Psychological comorbidities are important prognostic factors for low back pain (LBP). To develop improved treatment paradigms, it is first necessary to characterize and determine current patterns of treatment in this population. Identify how comorbid depression or anxiety in patients with LBP is related to use of healthcare resources. Retrospective cohort study using electronic health records from outpatient offices at a large multisite academic medical center. Data from 513,088 unique patients seen between January 2010 and July 2020 (58.0% female, 52.6±19.5 years) with a diagnosis of LBP, indicated by predetermined ICD-9 and ICD-10 codes. Average self-reported pain scores, absolute differences and unadjusted risk ratios to compare opioid use, emergency department visits, hospitalizations, advanced imaging orders, spinal injections, and back surgeries between cohorts. Clinical characteristics and data regarding use of healthcare resources were extracted from the electronic health record. Clinical features and patterns in healthcare utilization were determined for patients with depression or anxiety compared to those without. Depression or anxiety was coded for 21.4% of patients at first LBP visit. Those with depression or anxiety were more likely to be on opioids (unadjusted risk ratio: 1.22, CI: [1.22,1.23]), go to the emergency department (1.31 [1.30-1.33]), be hospitalized (1.15 [1.13, 1.17]), receive advanced imaging (1.09 [1.08, 1.11]), receive an epidural steroid injection (1.16 [1.15, 1.18]), and less likely to have back surgery (0.74 [0.72, 0.77]). Differences in pain scores for those with depression/anxiety compared to those without were not clinically significant. Depression/anxiety is associated with increased use of healthcare resources, and is not associated with clinically meaningful elevated pain scores. Limitations come from use of an aggregate data set and reliance on administrative coding.

Incidence of low back pain and potential risk factors among pharmacists: A population-based cohort study in Taiwan.

Low back pain (LBP) is one of the most common symptoms of work-related musculoskeletal disorders in pharmacists. This can impede the physical functions of the body and lead to incapacitation, resulting in significant social and economic burden. This study aimed to investigate the incidence and risk factors that correlate with LBP in Taiwanese pharmacists.A retrospective cohort study was conducted among all registered pharmacists aged 20 to 40 years using the National Health Insurance Research Database (2000–2013) in Taiwan. The LBP diagnosis was confirmed with one episode of hospitalization or at least three claimed outpatient visits for LBP. Data on workplace characteristics as well as comorbidities were also collected for the analyses. A Cox proportional hazard regression was used to estimate the risk factors for LBP.The incidence rate of LBP among pharmacists was 16.60% in this study. Older pharmacists (28.49%; P < .01) and those who worked at district hospitals (23.51%; P < .01) showed a higher proportion of LBP. Furthermore, after adjustment for selected potential confounding factors, female pharmacists [adjusted hazard ratio (aHR): 1.12, 95% confidence interval (95% CI): 1.01–1.24, P = .0354] and pharmacists with diabetes (aHR: 1.55; 95% CI: 1.20–2.01; P = .0008) and gout (aHR: 1.70; 95% CI: 1.37–2.09; P < .0001) had significantly higher risks of LBP.In conclusion, age was positively correlated with LBP, and the workplace was an important factor in the development of LBP in pharmacists. We suggest that pharmacists who work in district hospitals should pay more attention to the development of LBP.

How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study

BackgroundGiven the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care.MethodsWe identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2–4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication.ResultsIn our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1–4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1–3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5–9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0–3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: − 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08–0.23%), 0.44% (95%CI: 0.30–0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03–0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13–0.26%).ConclusionsPatients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

Reducing the prevalence of low-back pain by reducing the prevalence of psychological distress: Evidence from a natural experiment and implications for health care providers.

To determine whether exogenously reduced psychological distress reduces reported low-back pain (LBP) and is associated with reduced medical visits for LBP. National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 1998-2004. We estimate a fuzzy regression discontinuity model in which a discontinuity in the prevalence of psychological distress is identified by exogenous national events. We examine whether this discontinuity induced a corresponding discontinuity in the prevalence of LBP. We additionally estimate a regression discontinuity model to determine associated changes in medical visits with LBP as the primary complaint. The prevalence of LBP was discontinuously reduced by one-fifth due to the exogenous national discontinuous reduction in psychological distress. This discontinuity in LBP cannot be explained by discontinuities in employment, insurance, injuries/poisoning, general health status, or other factors. We find an associated three-fifth discontinuous reduction in medical visits with LBP as the primary complaint. On a monthly basis, 2.1 million (P<.01) adults ceased to suffer LBP due to the national reduction in psychological distress, and associated medical visits with LBP as the primary complaint declined by 685000 (P<.01).

Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States

ObjectivesThe objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED. MethodsWe conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014–2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS. ResultsThe study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014–2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001). ConclusionsIn a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS.

Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs.

The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. Compared with the delayed physical therapy group (n=94), the early physical therapy group (n=171) had a lower risk of receiving lumbar surgery (relative risk [RR]=0.47, 95% CI=0.26-0.86) and advanced imaging (RR=0.72, 95% CI=0.55-0.95), and they were less likely to have long-term opioid use (RR=0.45, 95% CI=0.28-0.76). The early physical therapy group incurred lower costs (mean=$3,806, 95% CI=$1,998-$4,184) than those in the delayed physical therapy group (mean=$8,689, 95% CI=$4,653-$12,727). Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12months following the ED visit. The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.

Use of Imaging During Emergency Department Visits for Low Back Pain.

OBJECTIVE. Back pain is one of the most common reasons for adult patients 18-65 years old to seek emergency care. Use of imaging for patients without so-called red flags (trauma, malignancy, or infection) may result in potentially unnecessary costs and radiation exposure. The aim of this study was to investigate the use of imaging for patients with emergency visits for low back pain. MATERIALS AND METHODS. Emergency department visits for patients with low back pain billed to insurance were identified by querying a national commercial claims and encounters database for patients 18-64 years old. Patients with concomitant encounter diagnoses suggestive of trauma or those with prior visits for back pain were excluded. Imaging modalities (radiography, CT, and MRI) were identified by Current Procedural Terminology codes. RESULTS. A total of 134,624 encounters met inclusion criteria. Imaging was obtained in 44,405 (33.7%) visits and decreased from 34.4% to 31.9% between 2011 and 2016 (odds ratio per year, 0.98 [95% CI, 0.98-0.99]; p < 0.001). During the study period, 30.9% of patients underwent radiography, 2.7% of patients underwent CT, and 0.8% of patients underwent MRI for evaluation of low back pain. The use of imaging varied significantly by geographic region (p < 0.001), with patients in the southern United States undergoing 10% more imaging than patients in the western United States. CONCLUSION. The use of imaging for the initial evaluation of patients with low back pain in the emergency department continues to occur at a high rate, in approximately one in three new emergency visits for low back pain in the United States.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use

ObjectiveThis study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).DesignA retrospective cohort study...

Healthcare Resource Utilization Among Patients With Non-Surgical Refractory Low Back Pain in the United States: A Retrospective Analysis of Health Insurance Claims Data

Abstract INTRODUCTION The economic burden of low back pain (LBP) in the US is estimated between $84.1 and $624.8 billion. Some patients with LBP that persists despite conventional medical management are ineligible for spine surgery and are considered to have non-surgical refractory back pain (NSRBP). We investigated the healthcare resource utilization (HCRU) of patients with NSRBP. METHODS The IBM MarketScan® Research databases were queried for adult patients with a diagnosis of LBP, excluding instability (eg, spondylolisthesis) and non-mechanical etiologies, and negative history of failed back surgery syndrome or spine surgery within the study period (2009-2016). For a patient to qualify as refractory, we required utilization for &gt;30 d of pain medications (prescribed within 2 wk of diagnosis) or non-pharmacologic therapies within the 3 to 24 mo following initial diagnosis. Annual total costs, including inpatient and outpatient service costs and outpatient medication costs, were calculated for 2 yr. RESULTS Among 50 801 patients, median total cost was $3,755 (IQR $1,299, $9,108) at 1 yr pre-diagnosis, reached $6,622 (IQR $2,723, $13,978) at 1 yr, and decreased to $5,977 (IQR $2,311, $13,307) at 2 yr. Costs were highest for patients with Medicare Supplemental (N = 7,053): median total cost was $10,198 (IQR $5,517, $18,584) at 1 yr, decreasing in the second year to $9,407 (IQR $4,737, $18,330). Outpatient services accounted for the majority of all costs. The proportion of patients with ≥4 outpatient visits for LBP was 56.6% within the first 6 mo, 50.0% in the 1st year, and 68.5% in the 2nd year. CONCLUSION For patients with NSRBP, the median annual total cost at 1 yr almost doubled the 1-yr prediagnosis cost and decreased for the 2nd year; most costs were due to outpatient services. Patients with Medicare Supplemental incurred the highest total costs. Most patients saw outpatient providers multiple times in the first 6 mo and throughout the 2 yr.

Using Public Cost Information During Low Back Pain Visits: A Qualitative Study.

Patients desire information about health care costs because they are increasingly responsible for these costs. Public Web sites that offer cost information could inform provider-patient discussions of costs at the point of care. To evaluate tools to facilitate the use of publicly available cost information during clinical visits for low back pain (LBP). Qualitative study using individual and group interviews and surveys. 6 rural primary care practices in 2 health systems in Maine. Practice staff (n= 50) and adult patients with LBP (n= 72). Participating health systems and practices were offered financial incentives, a series of trainings, and technical assistance to pilot tools for discussing costs of LBP care using CompareMaine.org, Maine's cost and quality transparency Web site. Integration of tools into workflow, awareness and value to providers, and patient experience were identified through 11 group interviews with practice staff (n= 25) and health system leaders (n= 11), provider (n= 25), and patient (n= 47) surveys; patient interviews (n= 5); and administrative data. The intervention increased provider and consumer awareness of CompareMaine.org, but minimally changed use in clinical discussions as a result of fewer-than-expected patients with LBP, limited system support, workflow barriers, and providers' reluctance to adopt the tools because of perceptions of limited value for their patients. In contrast, patients valued cost conversations and found the tools useful, and over one half reported intending to use CompareMaine.org during future care decisions. Generalizability was limited by the small number of practices and participants. Lower-than-anticipated participation precluded examination of the effect of the tool on the frequency of cost-of-care conversations. This multicomponent intervention to introduce publicly reported cost information into LBP clinical discussions had low provider uptake. Whereas cost conversations and CompareMaine.org were perceived as useful by participating patients with LBP, providers were uncomfortable discussing cost variation at the point of care. Successful use of public cost information during clinical visits will require normalizing use to a broader group of patients and greater provider outreach and health system engagement. Robert Wood Johnson Foundation.

(322) Worsening Depressive Symptoms after an Emergency Department Visit for Low Back Pain are Associated with Persistent Pain and Disability

More than 2.5 million U.S. emergency department (ED) visits each year are for low back pain (LBP). Nearly half of these patients report persistent pain and functional disability 3 months later. While baseline depression has been shown to predict these poor outcomes, little is known about whether persistent pain and disability correlate with worsening depression. This is a secondary analysis of 362 patients seen at an urban ED with LBP who completed the Roland-Morris Disability Questionnaire (RMDQ), a 0-10 pain numeric rating scale (NRS), and Patient Health Questionnaire depression subscale (PHQ-9) at their ED visit and 3 months later. Linear regression analysis was used to determine the association between changes in depression severity from index ED visit to 3-month follow-up, and changes in RMDQ and pain scores over the same period. Models were adjusted for age, gender, race, ethnicity, education, and depression severity at baseline. At the index ED visit, median PHQ score was 0 (IQR 0,4) and median RMDQ score was 22 (IQR 17,24). At one week, median pain score was 6 (IQR 2,8). At 3 months, median change in PHQ from baseline was 0 (IQR -24,23), change in RMDQ was -8 (IQR -20,0), and change in pain score was -1 (IQR -3,0). After adjusting for potential confounders, worsening depression score between the ED visit and 3 month follow-up was associated with worsening function (B=0.85, 95% CI=0.68-1.03) and pain scores (B=0.11, 95%CI=0.05-0.17). The 3-month disability and pain intensity outcomes were more strongly correlated with change in depression than with baseline depression scores. Future work among ED patients with LBP should consider progressive depressive symptoms as a potentially modifiable risk factor for persistent pain and disability.

Reference values of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in patients with lumbar spinal stenosis and characteristics of deterioration of QOL: Lumbar Spinal Stenosis Diagnosis Support Tool: DISTO project

BackgroundThe reference values of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with lumbar spinal stenosis (LSS) are still unknown. This multicenter cross-sectional survey was performed to determine the reference values and disease-specific characteristics of deterioration of QOL caused by LSS itself, not by aging, through comparison of patients with and without LSS who had an outpatient visit for low back pain by age and sex groups. MethodsThe present study was performed at 564 medical centers and clinics. The JOABPEQ was measured for 8338 patients aged 20 years or over who came to an outpatient clinic for low back pain (LBP) and were examined for whether they had LSS using the LSS diagnosis support tool (LSS-DST). Scores in the five JOABPEQ domains were compared between the LSS group and the LBP without LSS group (LBP group) for each age and sex group. ResultsScores for Pain-related disorder, Gait disturbance, Social life disturbance, and Psychological disorders were significantly lower in the LSS group than in the LBP group. ConclusionThe percentiles of JOABPEQ scores in patients with LSS were clarified and could be used as reference values. Deterioration of QOL caused by LSS itself, not by aging, are characterized by Pain-related disorder, Gait disturbance, Social life disturbance, and Psychological disorders.

August 2018 Letter to the Editor-in-Chief.

Letter to the Editor-in-Chief of JOSPT as follows: "Promoting Roles and Services Within Physical Therapy Not Supported by Evidence" with Authors' Response J Orthop Sports Phys Ther 2018;48(8):669-671. doi:10.2519/jospt.2018.0204.

Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes.

Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.

MP31: The contrarian effect: how does a Choosing Wisely focused knowledge translation initiative affect emergency physician practice in a high awareness-low investigation environment?

Introduction: We previously reported that a targeted knowledge translation (KT) intervention was associated with a trend towards increased awareness and knowledge of the Choosing Wisely Canada (CWC) emergency medicine (EM) recommendations. We wished to assess if the intervention changed physician practice, specifically looking at the imperative “do not order lumbar XRs for non-traumatic low back pain unless red flags exist”. Methods: A departmental KT initiative was implemented in April 2016 and consisted of a 1-hour seminar reviewing the CWC-EM recommendations, access to a video cast, departmental posters, and a before and after awareness survey. The effectiveness of our intervention was assessed by analyzing the frequency of lumbar XR imaging conducted for low back pain before and after the introduction of our intervention at a tertiary teaching hospital emergency department. All patient visits for the complaint of low back pain were included. The rates of XR imaging from June 2014 to September 2014 for the pre-intervention period and June 2016 to September 2016 for the post-intervention period were collected and analyzed using Fisher exact tests. A sample size of 683 was required to detect a 5% change with an alpha of 0.05 and a power of 80%. Results: Baseline characteristics of patients were similar for the pre- and post-intervention periods. There was a total of 781 patient visits for low back pain in June to September 2014 and 672 in June to September 2016. The XR imaging rate for low back pain increased from 12% (95% CI 9.9-14.5) to 16.2% (95% CI 13.6-19.2) following the intervention (p=0.023). Conclusion: We previously demonstrated a trend towards increased awareness and knowledge of the CWC EM recommendations following a knowledge translation initiative. Baseline XR imaging rates for low back pain were lower than what has been reported. We observed that our intervention was associated with an increased frequency of imaging for low back pain. This may be due to a contrarian effect. We feel this calls into question the role of knowledge translation initiatives where physician practice already closely adheres to pre-established recommendations.

Stagnant Physical Therapy Referral Rates Alongside Rising Opioid Prescription Rates in Patients With Low Back Pain in the United States 1997-2010.

A cross-sectional observational study utilizing the National Ambulatory and National Hospital Ambulatory Medical Care Surveys between 1997 and 2010. The aim of this study was to characterize national physical therapy (PT) referral trends during primary care provider (PCP) visits in the United States. Despite guidelines recommending PT for the initial management of low back pain (LBP), national PT referral rates remain low. Race, ethnicity, age, payer type, and PT referral rates were collected for patients aged 16 to 90 years who were visiting their PCPs. Associations among demographic variables and PT referral were determined using logistic regression. Between 1997 and 2010, we estimated 170 million visits for LBP leading to 17.1 million PT referrals. Average proportion of PCP visits associated with PT referrals remained stable at about 10.1% [odds ratio (OR) 1.00, 95% confidence interval (95% CI) 0.96-1.04)], despite our prior finding of increasing number of visits associated with opioid prescriptions in the same timeframe.Lower PT referral rates were observed among visits by patients who were insured by Medicaid (OR 0.48, 95% CI 0.33-0.69) and Medicare (OR 0.50, 95% CI 0.35-0.72). Furthermore, visits not associated with PT referrals were more likely to be associated with opioid prescriptions (OR 1.69, 95% CI 1.22-2.35). Although therapies delivered by PTs are promoted as a first-line treatment for LBP, PT referral rates remain low. There also exist disparately lower referral rates in populations with more restrictive health plans and simultaneous opioid prescription. Our findings provide a broad overview to PT prescription trend and isolate concerning associations requiring further explorations. 3.

Subsequent health-care utilization associated with early physical therapy for new episodes of low back pain in older adults

BackgroundThe association between early physical therapy (PT) and subsequent health-care utilization following a new visit for low back pain is not clear, particularly in the setting of acute low back pain. PurposeThis study aimed to estimate the association between initiating early PT following a new visit for an episode of low back pain and subsequent back pain–specific health-care utilization in older adults. Design/SettingThis is a prospective cohort study. Data were collected at three integrated health-care systems in the United States through the Back Pain Outcomes using Longitudinal Data (BOLD) registry. Patient SampleWe recruited 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain. Outcome MeasuresPrimary outcome was total back pain–specific relative value units (RVUs), from days 29 to 365. Secondary outcomes included overall RVUs for all health care and use of specific health-care services including imaging (x-ray and magnetic resonance imaging [MRI] or computed tomography [CT]), emergency department visits, physician visits, PT, spinal injections, spinal surgeries, and opioid use. MethodsWe compared patients who had early PT (initiated within 28 days of the index visit) with those not initiating early PT using appropriate, generalized linear models to adjust for potential confounding variables. ResultsAdjusted analysis found no statistically significant difference in total spine RVUs between the two groups (ratio of means 1.19, 95% CI of 0.72–1.96, p=.49). For secondary outcomes, only the difference between total spine imaging RVUs and total PT RVUs was statistically significant. The early PT group had greater PT RVUs; the ratio of means was 2.56 (95% CI of 2.17–3.03, p<.001). The early PT group had greater imaging RVUs; the ratio of means was 1.37 (95% CI of 1.09–1.71, p=.01.) ConclusionsWe found that in a group of older adults presenting for a new episode of low back pain, the use of early PT is not associated with any statistically significant difference in subsequent back pain–specific health-care utilization compared with patients not receiving early PT.