The Agency for Healthcare Research and Quality (AHRQ) released its weekly updates yesterday and I was pleased to see an update on the American College of Occupational and Environmental Medicine (ACOEM) Guidelines for low back disorders. These Guidelines can be downloaded from this page at www.guideline.gov
Here are just some of their major recommendations:
In the absence of red flags, primary care and occupational physicians or other health care professionals can effectively manage low back problems conservatively.
At the first visit, the physician should assure the patient that low back pain (LBP) is normal, has an excellent prognosis and, in most cases, is not debilitating on a long-term basis. Patients with elevated fear avoidance beliefs may require additional instructions and interventions to be reassured of this prognosis. Theoretically, this reassurance has the potential to avoid increasing the probability of the patient developing chronic pain syndrome.
All patients should be encouraged to return to work as soon as possible as evidence suggests this leads to the best outcomes. This process may be facilitated with modified duty particularly if job demands exceed patient capabilities. Full-duty work is a reasonable option for patients with low physical job demands and the ability to control such demands (e.g., alternate their posture) as well as for those with less severe presentations.
Physicians should be aware that “abnormal” findings on x-rays, magnetic resonance images, and other diagnostic tests are so common they are normal by age 40. Bulging discs continue to increase after age 40, and by age 60 will be encountered in 80% of patients. This requires that a careful history and physical examination be conducted by a skilled physician in order to correlate historical, clinical, and imaging findings prior to assigning the finding on imaging to a patient’s complaints. It is recommended that physicians unable to make those correlations, and thus properly educate patients about these complex issues, should defer ordering imaging studies to a qualified consultant in musculoskeletal disorders. Without proper education on prevalence, treatment, and prognosis, patients may become fixated on “fixing” their abnormality (which may in fact be a completely normal condition) and thus iatrogenically increase their risk of developing chronic pain.
Significant abnormalities in hip range-of-motion may increase the probability of back disorders.
There is evidence of efficacy for manipulation for treatment of non-specific LBP, particularly for those patients who test positive for the Clinical Prediction Rule.
I really like the www.guideline.gov site. It is at times hard to navigate with all the information so I have signed up for the weekly updates email blast here.
So how can we get PTs and Family MDs to read these Guidelines? My Top 5 (all dripping with sarcasm)
Post on the back of MRI reports
Hide inside the cover of Advance for PT
Enclose in a “guru” based Con Ed brochure
Make a Wii Interactive “Guidelines Game with Regis Phelbin asking you questions
Include with the side effects in the folded piece of paper that comes with your prescription narcotics and muscle relaxants
Seriously, how can we get the generic PT and the referring MD to utilize these Guidelines without waiting a decade for them to become accepted? How can we create change? (Source: MyPhysicalTherapySpace.com)
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