Top POEMs of 2011: Musculoskeletal Disease

Imaging for Low-Back Pain: Rarely Indicated, Often Harmful

Clinical Question: When should be diagnostic imaging be used for patients with low-back pain?

Bottom Line: X-rays and magnetic resonance imaging (MRI) for patients with low-back pain are associated with increased cost, poorer health in recipients, and an increased risk for surgery. Routine imaging of back patients is not warranted and, moreover, the indications for imaging are few: major risk factors for cancer, signs of cauda equina syndrome, and severe neurologic deficits. Radiography recommendations after a trial of therapy include weak risk factors for cancer, signs of ankylosing spondylitis in young patients, or vertebral fracture risk factors in older people. MRI should be limited to patients with radiculopathy or symptoms of spinal stenosis who don't respond to therapy. Using diagnostic tests for a putative therapeutic effect does not decrease patients' anxiety. (Level of Evidence: 1a)

Reference: Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181-189.

Study Design: Practice guideline

Funding Source: Foundation

Setting: Various (guideline)

Synopsis: These guidelines are based on a systematic review and meta-analysis of research investigating the usefulness of various imaging studies in patients with low-back pain. Based on a meta-analysis of 6 studies, routine imaging with x-ray, MRI, or computed tomography in patients without underlying conditions does not have any effect on pain, function, quality of life, or patient-rated improvement, and, contrary to common wisdom, does not alleviate patients' anxieties about back pain. These studies were done in patients with and without radiculopathy. Several studies have demonstrated that patients who had routine imaging will have more pain and worse overall health status. That's not to say that imaging won't pick up abnormalities; herniated or bulging discs and spinal stenosis are commonly found in asymptomatic patients, as well as in those with back pain, with up to 90% of asymptomatic individuals older than 60 years having a degenerated or bulging disc. Abnormal findings can lead to surgery that will not be effective since the exposed abnormality is simply coincident to the real cause of the pain. The guidelines suggest plain films, along with erythrocyte sedimentation rate determination for patients with major risk factors for cancer, and MRI for patients at risk for spinal infection (low-back pain, fever, intravenous drug use), signs of cauda equina syndrome, or severe neurologic deficits, such as progressive weakness or motor deficits at multiple neurologic levels.

Professor of Family Medicine
Tufts University
Boston, MA

Massage Improves Function in Patients with Chronic Low Back Pain

Clinical Question: Can massage improve disability and decrease symptoms in patients with chronic low back pain?

Bottom Line: Weekly massage for 10 weeks, either a general relaxation massage or one aimed specifically at addressing musculoskeletal contributions to low back pain, produces a clinically meaningful reduction in dysfunction and symptoms as compared with usual care. The effect diminishes but functional improvement persists for up to 1 year after the start of treatment. (Level of Evidence: 1b)

Reference: Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain. Ann Intern Med 2011;155(1):1-9.

Study Design: Randomized controlled trial (single-blinded)

Funding Source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis: These investigators invited adults with chronic (at least 3 months), nonspecific low back pain to participate in this study. A total of 401 patients were randomized, using concealed allocation, to receive 1 of 3 treatments: either of 2 different types of massage or usual care. Massage consisted of 10 weekly sessions using either relaxation or structural massage, the latter consisting of myofascial, neuromuscular, and other soft-tissue techniques. The usual care group received no specific care. At the end of 10 weeks, dysfunction, measured by the Roland Disability Questionnaire, improved an average of 2.5 and 2.9 points out of a possible 23 points with the 2 types of massage as compared with usual care. A difference of 2 points on this scale is considered clinically meaningful. Improvements were similar with either type of massage. "Bothersomeness" of pain, rated 5.6 to 5.8 on a scale of 1 to 10, decreased an average 1.4 and 1.7 points as compared with usual care. Differences in function scores diminished over time but were still present 1 year after the start of the study.

Professor of Family Medicine
Tufts University
Boston, MA

Bisphosphonate Use Associated with Increased Risk of Atypical Hip and Femoral Shaft Fractures

Clinical Question: Do oral bisphosphonates increase the risk of atypical hip and femur fractures in postmenopausal women?

Bottom Line: Oral bisphosphonate use for 5 years or longer is significantly associated with an increased risk of atypical hip and femur fractures (subtrochanteric or femoral shaft). A previous study (JAMA 2006;296:2967-38) found little if any benefit of extended bisphosphonate use beyond 5 years in reducing the risk of typical fractures of the femoral neck or intertrochanteric region. Although this study design (case-control) is classified as weak evidence (LOE = 3b), it may be the best we have for some time. Thus, practicing clinicians should consider stopping bisphosphonates for most women after 5 years, except for those at high risk (eg, chronic steroid users). (Level of Evidence: 3b)

Reference: Park-Wyllie LY, Mamdani MM, Juurlink DN, et al. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA 2011;305(8):783-789.

Study Design: Case-control

Funding Source: Government

Setting: Population-based

Synopsis: Current evidence on whether bisphosphonates increase the risk of subtrochanteric or femoral shaft fractures in postmenopausal women is uncertain. These investigators analyzed information obtained from multiple databases on the association between bisphosphonate use and fractures in a cohort of women in Ontario, Canada, 68 years or older, who initially started oral bisphosphonate (alendronate, risedronate, or etidronate) therapy between April 2002 and March 2008. Separate databases included information on drug prescriptions, hospitalizations, physician service claims, cancer, and basic demographic information. Cases included those women hospitalized with a subtrochanteric or femoral shaft fracture. Up to 5 women who were not hospitalized with similar fractures were matched to age and cohort entry date and served as control patients. Analyses were performed to adjust for other fracture risk factors. During the 7-year study period, 205,466 women commenced oral bisphosphonate therapy. Of these, 716 (0.35%) were hospitalized for an atypical subtrochanteric or femoral shaft fracture. The use of bisphosphonates for 5 years or longer, compared with transient or no use, was associated with a significantly increased risk of atypical hip or femur fracture (odds ratio [OR] = 2.74; 95% CI, 1.25-6.02). Among the 52,595 women using bisphosphonates for at least 5 years, a subtrochanteric or femoral shaft fracture occurred in 188 (0.36%) within 2 years. Duration of therapy of less than 5 years was not associated with an increased risk of fracture.

Vice Chair, Department of Family Medicine
University of Virginia
Charlottesville, VA

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