Survey Reveals High Rates of Disagreement Among Spine Surgeons on LBP Treatment

Ask 2 spine surgeons for a recommendation on what kind of spine surgery to have for low back pain (LBP)—or whether to have surgery at all—and you're likely to get 2 different answers, according to results of a new survey that found high rates of disagreement, with some significant regional variability.

In an article published recently in Spine (abstract only available for free), researchers shared results of a study in which 445 spine surgeons across the US (75% orthopedic surgeons, 25% neurological surgeons) were asked to respond to 2 case scenarios and related imaging. Scenario 1 described a 44-year-old man with mechanical LBP refractory to conservative management, no leg pain, and discogram at L4-5 causing concordant pain; L3-4 and L5-S1 were negative controls. Scenario 2 presented the same patient, but with discogram at L4-5 and L5-S1 causing concordant pain, and L3-4 a negative control. The surgeons were instructed to provide their recommendation by choosing 1 of 4 fusion surgeries, or no surgery at all.

Authors analyzed the results by geographic region, practice setting, years of experience, and other factors. Here's what they found:

Overall disagreement on how to proceed was 75%-76%, with significant geographic variation. Even in the regions and scenarios with the highest rate of agreement—scenario 1 in the Midwest, and scenario 2 in the Southeast—more than 2 out 3 surgeons (69%) provided differing recommendations. The highest rates of disagreement occurred in the Southwest for both scenarios, with disagreement rates of 82% for scenario 1 and 85% for scenario 2.

The rates at which "no surgery" was recommended also varied by region.Overall, no surgery was recommended 41.4% of the time, ranging from a low of 29% in the Southwest for both scenarios to 52% in the Midwest for scenario 1, and 50% in the Northeast for scenario 2.

Practice setting played a big role in whether a surgeon recommended no surgery. Researchers found that surgeons in academic practice were nearly 4 times more likely to choose no surgery than surgeons in hybrid and private practice settings. Similarly, surgeons with fellowship training were twice as likely to select no surgery as a first option than surgeons without that training.

Practice setting also seemed to be related to disagreement rates. Surgeons in academic settings had a 56% disagreement rate, compared with 78%-79% disagreement rates among surgeons in hybrid or private practice settings.

Generally, the less-experienced surgeons recommended no surgery more often—and also agreed with each other at higher rates. Surgeons with fewer than 5 years' practice duration recommended no surgery at a 56% rate in scenario 1 and a 60% rate in scenario 2, with rates of disagreement at 65% and 61%, respectively. Surgeons with more than 20 years in practice disagreed at 77% and 80% rates for the 2 scenarios, and chose no surgery 41% of the time for scenario 1 and 36% of the time for scenario 2.

"The lack of definitive evidence supporting one surgical approach versus another, and the lack of definitive evidence identifying the indications for surgery among this patient population, is a major contributor to this variability," authors write. "This heterogeneity … is concerning as it implies patients can present with the same pathology to different surgeons and receive entirely different surgeries, or no surgery."

Authors recommend that surgeons do something about the wide variability, particularly in light of health care's march toward value-based care rooted in identifiable outcomes. "It is imperative that spine surgeons be proactive in defining what works best for their patients, or it is quite possible that such will be dictated to them by other stakeholders (i.e., payers)," they add.

Authors hope that acknowledging this variability "will spur additional studies aimed at identifying the indications as well as the most cost-effective treatments for LBP." In the meantime, they recommend that "patients should be involved in the decision-making process to identify the optimal treatment based on their values."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


Posted by News Now Staff at 1:20 PM


Cupping and Gua Sha


Since the Olympics began last Friday we've seen a lot of bruise marks on the athletes. These bruises are coming from a technique called cupping.  This technique has been practiced in Chinese Medicine for many, many years.

In the Olympics cupping is being used to improve circulation and loosen and decompress the muscle and fascia or connective tissue that underlies that area.  But not only the athletes benefit from cupping! 

It can also be used to help relax overactive muscles which allows us as physical therapists to teach the patient how to turn on the other muscles that have shut down due to injury or pain.  Many patients have increased muscle tone and tightness of their tissues in their areas of pain, specifically neck and back pain.  Cupping over these areas and sliding the cup as you'll see in this video helps to release some of that tightness in the tissue.


Gua Sha tools are also effective for releasing the muscles and fascia as well. 

Both are these techniques are not painful and tolerated very well. 
Let us know if you have any questions about cupping/Gua Sha and if you think it would benefit you!!

CDC: Physical Therapy, Other Non-Drug, Non-Opioid Approaches Should be First-Line Treatment for Chronic Pain

In its final version of guidelines for prescribing opioids for chronic pain, the US Centers for Disease Control and Prevention (CDC) minces no words about the importance of physical therapy and other nondrug/nonopioid approaches, and delivers a clear message that physical therapists (PTs) and physical therapist assistants (PTAs) have known for some time: there are better, safer ways to treat chronic pain than the use of opioids.

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain," the CDC states in its first recommendation. "The contextual evidence review found that many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as [cognitive behavioral therapy, or CBT], and certain interventional procedures can ameliorate chronic pain."

The CDC guidelines were created in response to growing rates of opioid use disorder and opioid overdose, a problem fueled by ever-increasing rates of opioid prescriptions written by primary care providers—approximately 259 million prescriptions written in 2012 alone. In its introduction to the guideline, CDC cites from 1 study that among 15- 64-year-olds who received opioids for noncancer pain, 1 in 550 died from an opioid-related overdose at a median of 2.6 years from their first prescription.

A draft version of the guidelines were published in late 2015 as part of a CDC call for comments. APTA responded with strong support for the recommendations, writing that approaches such as physical therapy "have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."

Other stakeholders were less enthusiastic. According to a report from National Public Radio, some critics questioned the CDC recommendation against using opioids as a first-line treatment for chronic pain.

In that NPR report, Debra Houry, director of CDC's National Center for Injury Prevention and Control, responded by pointing to weak evidence supporting the benefits of opioids for chronic pain and growing evidence pointing to the risks. "We have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted," Houry said. "On the other end, nonopioids, there is evidence for their benefits."

In addition to the statement around first-line treatment, the CDC guideline includes recommendations that address the importance of establishing treatment goals, discussing risks of opioids with patients, choosing appropriate dosage and release factors, and conducting thorough follow-up assessments once a patient has been prescribed an opioid. The guidelines are not intended to apply to opioid use related to patients with cancer, palliative, or end-of-life care.

News of the CDC guidelines spread quickly, with major media outlets includingNewsweekUSA TodayThe Wall Street Journal, and others reporting on the recommendations that arrive amidst increased national attention on the epidemic of opioid abuse and heroin use across the country. APTA is participating in a White House initiative to address the problem through, among other things, increased public awareness.

Those APTA public awareness efforts include a page on, the association's website for consumers looking for information on physical therapy, with information on the risks of opioids and physical therapy's role in the treatment of pain.

In addition to the guideline, CDC also released a checklist and fact sheet that outline the basics of the larger document. Both stress that nonopioid therapies should be "tried and optimized" before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids.


Posted by News Now Staff at 4:35 PM

Labels: Health Care Headlines

Wednesday, March 9, 2016

Newest Report on Burden of Musculoskeletal Conditions Now Available

The latest edition of a wide-ranging report brings high-powered data to something physical therapists and physical therapist assistants know at a very personal level—the overwhelming prevalence of musculoskeletal conditions among the US population.

The US Bone and Joint Initiative's (USBJI) newest revision of "The Burden of Musculoskeletal Diseases in the US" compiles extensive data on a wide range of conditions, including low back pain, neck pain, arthritis, osteoporosis, and injuries. The report also looks at musculoskeletal conditions in children, adolescents, and special populations, and offers insight on economic impact.

According to USBJI, half of all adults in the US were diagnosed with a musculoskeletal condition in 2012, with nearly 6% of the population reporting a condition that made them unable to perform at least 1 common activity, such as walking, getting out of a chair, or bathing. Back or neck pain accounted for 290.8 million lost workdays in 2012 alone.

The website allows free access to all data and features a "report builder" resource that allows visitors to select particular datapoints among the resources and create a customized report.

USBJI hopes that the resources will help to highlight the need for more attention on prevention and treatment of an area of health that is placing an enormous burden on the health care system.

"When musculoskeletal disorders that could be prevented or ameliorated are not addressed in a timely manner, we miss opportunities to intervene earlier and more effectively in the disease process—a program exacerbated by lack of access to both screening and treatment," USBJI writes in an executive summaryof the report. "These missed opportunities rob people of their ability to work and live full lives, and add unnecessary expenditures to the health care system."

APTA is a founding member of USBJI.

Article appears in PT in Motion News.