Managed Physical Medicine

Alternative Treatment Trends #2: Conservative Care and Advanced Imaging

Advanced imaging is a popular – and expensive – first course of action for patients with lower back pain – but does it always pay off?

Approximately 80 percent of adults experience some form of lower back pain (LBP) in their lifetime. It’s so common, in fact, that it is discussed at 1 in every 17 primary care visits. Such prevalence has prompted an unprecedented focus on the diagnosis and management of LBP patients. Yet despite our increased understanding of back pain, LBP-related costs have increased, with the United States spending more than $86 billion on direct LBP-related costs in 2005, and $1500-$2000 per individual in direct costs.

Conservative Care as First Treatment

A 2015 study published in Health Services Research (Fritz et al) sought to investigate the high cost of advanced imaging for patients with uncomplicated LBP. In particular, the research team compared the healthcare utilization and LBP-related charges of patients who received advanced imaging versus the more conservative physical therapy as the first management strategy.

In a study of 841 people who required additional care following a primary care appointment for uncomplicated LBP, Fritz and colleagues found that those who were first sent for MRIs were more likely to receive a surgical or injection intervention, require specialty care or visit an emergency department. In addition, these individuals saw LBP-related charges averaging $6,193. That’s $4,793 more than those who were first administered physical therapy.

The Psychology of Advanced Imaging

Research suggests that advanced imaging is a more costly first step and, in the absence of specific symptoms, may not deliver significant clinical benefit during this early stage of treatment (Chou 2009). So why do MRIs continue to be so common, especially given their high price tag? In the discussion section of her study, Fritz explains that the reasons often have more to do with psychological matters than lumbar concerns.

  1. Patient expectations: When a patient sees a primary care physician for LBP, he or she is typically looking for a diagnosis and a curative, or at least pain-relieving treatment. Many patients believe that back pain is a sign that the spine has become abnormally positioned and must be corrected or risk becoming unsound or unreliable on a daily basis. This often leads them to push for advanced imaging – and to view denial of such services as an unfavorable response. Consumer research suggests that offering an alternative to replace the broken expectation is important in these instances. Physical therapy, which is viewed as a credible form of treatment, is often an ideal and agreeable alternative.
  2. Labeling: Identifying and labeling the source of pain through advanced imaging can provide patients with a sense of satisfaction, but this can also lead to heightened concern – and even catastrophic thinking, a known psycho-social barrier to recovery. As an alternative, conservative clinical care (e.g., physical therapy) may be a way to avoid the negative consequences of labeling and deter additional care-seeking while, at the same time, yielding clinical outcomes similar to those who first undergo lumbar imaging (Chou 2009).
  3. Specialty care vs. self-care: The care-seeking prompted by advanced imaging can often lead patients down a road of specialists and procedures, rather than encouraging them to actively participate in the management of their condition. A major component of physical therapy is engaging patients in their treatment and educating them about their pain – including the fact that most uncomplicated back pain subsides over time. This approach often motivates patients to contribute to the management of their back pain away from the clinic. Additionally, it has been suggested that the self-management strategies learned in physical therapy may play an important role in long-term care and help patients avoid recurrent cases.

The study by Fritz et al reaffirms a growing body of research suggesting that while advanced imaging can be extremely valuable in certain contexts, it may not be a necessary course of treatment in the initial management of uncomplicated LBP. For the right patients, physical therapy will often prove to be an ideal alternative as the less invasive and less costly option. But perhaps even more valuable, by collaborating with a physical therapist in their own care, patients may find that the road to recovery is one they can largely walk on their own.

Bibliography

Chou, R., Fu, R., Carrino, J. A., & Deyo, R. A. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet, 373(9662), 463-472.

Escolar-Reina, P., Medina-Mirapeix, F., Gascón-Cánovas, J. J., Montilla-Herrador, J., Valera-Garrido, J. F., & Collins, S. M. (2009). Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Archives of physical medicine and rehabilitation, 90(10), 1734-1739.

Fritz, J. M., Brennan, G. P., & Hunter, S. J. (2015). Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health services research, 50(6), 1927-1940.

Murphy, D. R., & Hurwitz, E. L. (2011). Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropractic & manual therapies, 19(1),

Optum (2014). Conservative back treatment maximizes quality and affordability. Retrieved from www.optum.com/content/dam/optum/resources/whitePapers/ConservativeArticle_112211.pdf

Zusman, M. (2013). Belief reinforcement: one reason why costs for low back pain have not decreased. Journal of Multidisciplinary Healthcare, 6, 197–204. http://doi.org/10.2147/JMDH.S44117