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Q&A with Dr. Mitra

Academy member Raj Mitra, MD, chair of AAPM&R’s Choosing Wisely® Task Force, discusses AAPM&R’s participation in the Choosing Wisely campaign—an initiative of the American Board of Internal Medicine (ABIM) Foundation—and the significance of this campaign to AAPM&R members.

Can you provide some background information about the Choosing Wisely campaign?

This important initiative was started by the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

Choosing Wisely aims to promote conversations between providers and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

To spark these conversations, leading specialty societies have asked their members to create lists of “Things Physicians and Patients Should Question.” These lists are evidence-based recommendations that should help facilitate discussion between doctors and patients to help make wise decisions about the most appropriate care based on a patient’s individual situation.

Why did AAPM&R create the Choosing Wisely Task Force?

AAPM&R established a Choosing Wisely®  Task Force to develop its list of “Things Physicians and Patients Should Question.” To ensure broad representation across our diverse specialty, members of this group were selected from various practice settings and subspecialties within PM&R.

Our objective was to identify key topics, which were evidence based and representative of our fellow Academy members—with the hope of triggering a dialogue between physiatrists and their patients about the utilization of important diagnostic tests and treatments.

What are AAPM&R’s Choosing Wisely Task Force 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 non-traumatic 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, Hagen KB. 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.

Can you explain the process the list went through for approval with AAPM&R and the ABIM Foundation? How did the task force respond to feedback received throughout the approval process?

The task force developed a list of topics they felt had the most impact on the field.  There was an extensive process of rating the topics based on their relevancy to the Choosing Wisely campaign, reconciling the topics with high-level evidence, and vetting the topics with AAPM&R’s EBP and QPPR Committees and then with AAPM&R’s Board of Governors (BOG). Additionally, we involved specialty consultants who were fellow AAPM&R members and experts on the topics to ensure that our topics and literature were accurate and up to date.

Once approved by the BOG, the Academy’s “5 things” list was sent to the ABIM Foundation for feedback. The ABIM Foundation asked 2 physicians to review the list for clarity and to offer comments to AAPM&R. The ABIM Foundation provided their feedback, and the process was then repeated to respond to the feedback from the ABIM Foundation.  

What value do you feel the Academy’s list will bring to AAPM&R members?

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. 

How does the work you’re doing with the Choosing Wisely Task Force relate to the innovative work you are currently doing in your practice?

Our goal in the department of rehabilitation medicine at Kansas University Medical Center is to offer the best evidence-based care to our patients. I am certain that AAPM&R’s Choosing Wisely topics will be a resource and guide for our clinicians to have a conversation about routine diagnostic tests and treatments, especially with spine and pain medicine.



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Thank You to AAPM&R’s Choosing Wisely Task Force Members

  • Anthony Chiodo, MD, General and Medical Rehabilitation Council
  • Nitin Jain, MD, Musculoskeletal Medicine Council
  • Raj Mitra, MD (Chair), Evidence Committee
  • Elliot Roth, MD, Evidence-Based Practice Committee
  • Maurice Sholas, MD, Pediatric Rehabilitation/Developmental Disabilities Council
  • Andrew Sherman, MD, Reimbursement and Policy Review Committee
  • Deborah Venesy, MD, Pain Medicine/Neuromuscular Medicine Council
  • Douglas Wayne, MD, Quality, Practice, Policy, and Research Committee
  • Lyn D. Weiss, MD, Health Policy and Legislation Committee
  • Jennifer Zumsteg, MD, Central Nervous System Rehabilitation Council