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  • Experts: It's Time to Act on the Evidence for Low Back Pain

    Recent features on Good Morning America and WebMD aside, the idea that low back pain (LBP) is best managed through nondrug, nonsurgical approaches isn't exactly news to physical therapists (PTs) and physical therapist assistant (PTAs). What would be news is if health care systems and providers widely accepted that reality and began taking steps to apply evidence to practice and payment.

    The latest rise in media attention on LBP was sparked by a recent series of articles published in The Lancet (free registration required) that highlighted the lack of adherence to clinical practice guidelines advocating "self-management, physical and psychological therapies" as first-line treatment for LBP. It's a disconnect that authors believe deserves immediate attention, given that LBP is the leading cause of disability worldwide, and is a condition that is increasing more rapidly in low-income and middle-income countries, according to the Lancet articles.

    The problem, according to the authors, is that despite the evidence, many providers—including some PTs—still recommend rest and time off work, and the use of drugs and surgery is more prevalent than it should be.

    "The message here is the critical need to close the evidence-practice gap across all aspects of spine care," said Julie Fritz, PT, PhD, FAPTA, a co-author of the study. "This message applies to physical therapy as [much as] it does to all other providers who may continue to advocate for overuse of ineffective treatments such as opioids and imaging. Professional stewardship demands that we examine our own profession even as we critique aspects of practice in other professions."

    By way of example, the Lancet articles point out that physical modalities such as transcutaneous electrical stimulation (TENS) or ultrasound have been found to be ineffective but often are recommended by PTs in many countries. One study cited found that 75% of US PTs used lumbar traction, and 38% of Swedish PTs used TENS; another cited study from India reported that one-third of PTs preferred physical modalities as first-line interventions.

    The gap is even more prevalent when it comes to the use of psychological therapies in combination with physical modalities—an approach that has proven to be effective. According to the Lancet articles, a recent study found that just 8.4% of patients with LBP in the US were prescribed cognitive behavioral therapy.

    "Care for patients with chronic conditions such as low back pain is inherently multidisciplinary," says Fritz. "There are opportunities for innovative care delivery models that integrate mental and physical health care providers, and PTs should welcome the chance to be a part of these programs. Triaging patients based on their mental health needs should be a part of physical therapist practice in the same manner as triage for physical needs."

    According to the Lancet authors, the problem isn't just about lack of action by providers—patient barriers to proper care for LBP also play a role in the problem on a worldwide scale. Authors advocate changes from health care systems that often reimburse surgery or medication over other interventions to systems that reimburse only evidence-backed treatments. Experts also recommend the development of "clear care pathways, referral, funding, and information technology systems" that would help clinicians deliver the most effective care at the right time.

    "All countries seem to be struggling with the same fundamental problem of closing the evidence-practice gap for patients with low back pain but there are lessons to be learned," Fritz observes. "Payment models in other countries are quite different from our fee-for-service model in the United States. These payment models certainly influence the overutilization of high-cost, low-value care such as back surgery. Other countries are also beginning to modify the basic care pathways for musculoskeletal pain conditions, with greater opportunity for physical therapists to serve as first-contact providers. Efforts in the Netherlands and United Kingdom, among others, bear watching."

    Upcoming Issue of PTJ Focuses on Building the Evidence Base for Physical Therapy in Pain Management

    When it comes to promoting better, safer ways to manage chronic pain, the physical therapy profession is motivated and enthusiastic—and that's exactly the kind of energy that needs to be applied to pursuing evidence that supports physical therapy's role in transforming care, say authors of a guest editorial in an upcoming issue of PTJ (Physical Therapy) devoted exclusively to pain and pain management. The editorial was released ahead of issue publication.

    The special May issue "serves as a reminder that there are lessons still to learn about optimizing nonpharmacological pain management," write guest co-editors Steven George, PT, PhD, FAPTA, an APTA member and director of medical research at the Duke Clinical Research Institute; and Arlene Greenspan, PT, MPH, DrPH, associate director of science and injury prevention and control at the Centers for Disease Control and Prevention (Greenspan's contributions were made as a personal outside activity). They describe the upcoming issue as "a good indication of the current state and possible future" of nonpharmacological approaches to pain.

    According to George and Greenspan, articles in the special issue are rooted in 4 basic priorities that have emerged as pain management and the use of opioids have received national attention: gaining a better understanding of how acute pain becomes a chronic condition; ensuring better access to frontline nonpharmacological treatments; developing ways to foster self-management of chronic pain; and advancing implementation of strategies proven to be clinically effective.

    But that doesn't mean the papers are repetitive in focus or approach. "Because pain is an individual phenomenon with tremendous variation in its presentation, the papers in this special issue cover different approaches, techniques, and philosophies," the editors write. Topics in the issue include psychologically informed practice, mechanism-based approaches, and sleep disturbances, with original research papers on topics including pain neuroscience education, rates of health care use after physical therapy, and the effectiveness of a home-based, telephone-supported physical activity program.

    "These papers showcase diversity in approaches, techniques, and philosophies needed to make meaningful progress," write George and Greenspan. "Perhaps most important, these papers convey the complexities involved with providing effective nonpharmacological options for pain relief."

    George and Greenspan believe that, collectively, the articles in the pain issue support the physical therapy profession's commitment to positive change.

    "Our profession's vision is to transform society by optimizing movement to improve the human experience," they write. "At this time in history, few societal needs are more urgent than improving a physical therapist's ability to deliver effective nonpharmacological pain management."

    PTJ is APTA's scientific journal, available for free to all APTA members. The journal is published online. Look for the special issue on pain in late April.

    Want to understand the basics of pain and the role for physical therapy? Check out George's online course "A Primer on Pain for the Practicing Physical Therapist," available in the APTA Learning Center. And be sure to catch this year's Rothstein Roundtable at the 2018 NEXT Conference and Exposition, "Physical Therapy Decreases Opioid Use: What Will It Take to Change Policy?"

    CMS, APTA: OIG Report on Outpatient Physical Therapy Claims Contains Possible Flaws and Questionable Assumptions

    A US Department of Health and Human Services Officer of the Inspector General (OIG) report makes claims about physical therapy billing under Medicare, and both the US Centers for Medicare and Medicaid Services (CMS) and APTA are pointing out how flawed processes and misinterpretations are coloring the findings.

    The OIG report, issued in late March, is based on a random sample of 300 Medicare outpatient claims for physical therapy made in 2013. According to the report, OIG was looking for instances in which claims were made for services that were not medically necessary, properly coded, or properly documented. The review, which identified 184 noncompliant claims totaling $12,741, extrapolated that the pattern indicates that Medicare may have paid out as much as $367 million in physical therapy claims that didn't meet CMS standards.

    CMS was quick to disagree with many of the OIG findings, arguing that a more thorough analysis would be required to back up the OIG estimate. Additionally, CMS pointed out that the OIG misinterpreted CMS coverage policies related to the concept of "significant improvement." That interpretation ignored CMS policy, clarified through the settlement in the Jimmo v Sebelius case, that puts an end to the "improvement standard" myth. "Most of the findings identified by OIG are likely attributable to documentation errors as opposed to fraudulent activity," according to statement from CMS.

    APTA has also taken issue with the OIG findings. In addition to supporting CMS' position that OIG's analysis included a flawed interpretation of the "improvement standard," the association also points out that the OIG study panel failed to include a single physical therapist on the team that reviewed claims and documentation. "Given the potential for misinterpretation of Medicare policy on outpatient therapy services and the role of physical therapists, APTA supports the inclusion of a physical therapist as part of the team conducting such reviews," APTA wrote in response to requests for comment on the report.

    "This report is 1 of hundreds of such documents produced by OIG every year—by no means is physical therapy singled out in the broader context of the OIG's work," said Justin Elliott, APTA vice president of government affairs. “However we agree with CMS that further analysis of the sampled claims is warranted to determine if the OIG findings accurately align with Medicare payment policy.”

    "APTA has always been committed to ensuring that outpatient physical therapy services meet Medicare requirements," Elliott said. "We also stand ready to work with CMS on providing additional education and resources for providers on correct coding, billing, and documentation, as well as identifying administratively burdensome requirements, which may be contributing to provider confusion and reporting errors.”

    The importance of accurate claims and documentation has been at the forefront of APTA education for years, particularly in 2013, when functional limitation reporting and G-codes were introduced, and later in 2016, when CMS adopted a tiered Current Procedural Terminology (CPT) coding system. This year, APTA launched retooled web resources on defensible documentation.