AAPM&R Releases List Of Commonly Used Tests And Treatments To Trigger Patient Conversation

February 1, 2013

AAPM&R participates in Choosing Wisely® initiative to encourage physician and patient conversations about patient care

[Rosemont, IL] – The American Academy of Physical Medicine and Rehabilitation (AAPM&R) today released a list of specific tests or procedures that are commonly ordered but not always necessary in physical medicine and rehabilitation (PM&R) as part of Choosing Wisely®, an initiative of the ABIM Foundation. The list identifies five targeted, evidence-based recommendations that can support conversations between patients and physicians about what medical care is necessary.

AAPM&R’s list identified the following five recommendations:

1. Don’t order repeat epidural steroid injections without evaluating the individual’s response to previous injections.
   Utilization of repeat epidural steroid injections has not been shown to improve patient outcomes. Physicians should consider patient re-evaluation prior to repeat epidural steroid injections.
   Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review. Arch Phys Med Rehabil. 2008;89:543–552.
2. Don’t order an EMG for low back pain unless there is leg pain or sciatica.
   Utilization of EMG studies for diagnosis of low back pain without leg pain is not supported. EMG studies have good specificity for the detection of lumbosacral radiculopathy in sciatica patients when appropriate electrodiagnostic criteria are used.
   Tong HC. Specificity of needle electromyography for lumbar radiculopathy in 55- to 79-yr-old subjects with low back pain and sciatica without stenosis. Am J Phys Med Rehabil. 2011 Mar;90(3):233–238.
3. Don’t prescribe bed rest for acute localized back pain without completing an evaluation.
   Prolonged bed rest (more than 2 days) in acute localized low back pain has not been shown to improve long-term function or pain. Bed rest prescriptions should be limited to less than 48 hours in patients with nontraumatic acute localized low back pain in the absence of traditional red flag signs, including but not limited to, tumors, neurological issues, and weakness.
   Dahm KT, Brurberg KG, Jamtvedt G, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612.
4. Don’t order an imaging study for back pain without performing a thorough physical examination. 
   A thorough history and physical examination are necessary to guide imaging decisions. Ordering spine imaging without obtaining a history and physical examination has not been shown to improve patient outcome and increases costs. 
   Chou et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181–189.
5. Don’t prescribe opiates in acute disabling low back pain before evaluation and a trial of other alternatives is considered. 
   Early opiate prescriptions in acute disabling low back pain are associated with longer disability, increased surgical rates, and a greater risk of later opioid use. Opiates should be prescribed only after a physician evaluation by a licensed health care provider and other alternatives are trialed. 
   Webster BS. Verma SK. Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007;32:2127–2132.

“The Choosing Wisely campaign will bring tremendous value to the doctor-patient decision-making process. Each topic is presented with a small summary as well as a reference; the objective is to trigger a dialogue and it should be clear that the final decision is up to the physician and their patient,” says Dr. Raj Mitra, chair of AAPM&R’s Choosing Wisely® Task Force. AAPM&R established a Choosing Wisely® Task Force which included physiatrists from various practice settings and subspecialties within PM&R in order to represent this diverse specialty.

The mission of the AAPM&R Task Force was to identify key topics, which were evidence based and representative of our fellow Academy members—with the hope of encouraging a dialogue between physiatrists and their patients about the utilization of important diagnostic tests and treatments.

To date, nearly 100 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of these new lists, the campaign will have covered more than 300 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss.

The campaign also continues to reach millions of consumers nationwide through a stable of consumer and advocacy partners, led by Consumer Reports—the world’s largest independent product-testing organization—which has worked with the ABIM Foundation to distribute patient-friendly resources for consumers and physicians to engage in these important conversations.

To learn more about PM&R, visit www.aapmr.org. To learn about Choosing Wisely and view the complete lists and recommendations, visit www.ChoosingWisely.org.

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AAPM&R is the national medical specialty society of more than 8,000 physical medicine and rehabilitation physicians, also called physiatrists. Rehabilitation physicians are nerve, muscle, brain and bone experts who treat injuries or illnesses that affect how you move.