Care Pathways Matter by Sheila Yonemoto, PT

At the recent Physical Therapy Tristate Conference, one of the talks was on the problem of pain in the United States. It's no wonder since there is an epidemic on opioid use. Some of the lesser-known facts about opioids include: Opioid use was promoted by an editorial in a medical journal, not a study; Low back pain is the number one condition for which opioids are prescribed.

It is estimated that 1 out of 4 people who are prescribed opioids go on to chronic abuse. It has been shown that patients who are referred to physical therapy in the first 90 days of pain have fewer doctor visits, deceased MRI's, decreased surgery, decreased injections, decreased opioid use and overall decreased medical costs.

It turns out that if patients are given an MRI first before physical therapy, they are 5 times more likely to have injections and 4 times more likely to have surgery. On average, less than 7% of patients received physical therapy in the first 90 days.

Where you enter the medical care system determines which pathway of care you take. Entering the physical therapy, chiropractic or acupuncture pathway ends up in lower costs, low opioid usage and more functional outcomes. Getting MRIs before these types of care leads to more use of opioids and surgery. Advanced imaging tests like MRIs often will show degenerative changes even with people who have no pain or functional loss. Changes in the joints are normal with aging, similar to wrinkles on the face, and don't necessarily mean that surgery is necessary.

There was an article in the newspaper about a sports injury orthopedist who did MRIs on professional athletes who were at the top of their game and had no problems with their joints. He state that he could justify almost any surgery by the MRI tests to any insurance company, even though there was no need for surgery. He further stated that there are probably a fair number of unnecessary surgeries performed because of these MRI results. What's more, the speaker said there is a 75% disagreement among surgeons on how to treat the patient after looking at the MRI.

in 2011, long-term outcomes were looked at in a Worker's Compensation population for 725 back fusions. One in four went on to have a second surgery. One in three had serious complications. There out of four never returned to work.

A Swedish study showed no change in outcome after 10 years with conservative care versus surgery.

In summary, patients did better and costs were significantly less, when they went on the pathway of conservative care, manual therapy and exercise. It also turns out that, much to the surprise of healthcare providers, 78% of patients prefer to try methods other than drugs or surgery.