ACA & Choosing Wisely
Five Things Clinicians and Patients Should Question
ACA has released a list of “Five Things Clinicians and Patients Should Question” in chiropractic as part of the Choosing Wisely® campaign, led by the ABIM Foundation and Consumer Reports®. The list identifies five targeted, evidence-based recommendations that can support doctors of chiropractic and patients in making wise choices about their care. Choosing Wisely® recommendations are designed to spark conversations between patients and their clinicians about the best, most appropriate care. The recommendations are not intended to prohibit any particular treatment in all scenarios or to dictate care decisions. They are also not intended to establish coverage decisions or exclusions. Rather, they should be viewed as opportunities to educate patients about health care procedures that are common, but whose usefulness in some cases is not supported by evidence. ACA’s Choosing Wisely® recommendations were developed by the association's Committee on Quality Assurance and Accountability, and approved by the ACA Board of Governors, after an extensive search of the most current scientific evidence on management and treatment options and months of careful review and consideration. ACA’s list features the following five recommendations:
1. Avoid routine spinal imaging in the absence of clear clinical indicators for patients with acute low back pain of less than six (6) weeks duration.
Multidisciplinary evidence-based guidelines recommend against the routine use of spinal imaging for patients with acute low back pain of less than six weeks duration in the absence of clear clinical indicators. Such indicators include, but are not limited to, history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms, and infection. Doctors of chiropractic must also consider conditions that potentially preclude a dynamic thrust to the spine, which include but are not limited to, osteopenia, osteoporosis, axial spondyloarthritis and tumors. Unnecessary imaging incurs monetary cost, exposes the patient to ionizing radiation, and can result in labeling patients with conditions that are not clinically meaningful, creating a false sense of vulnerability and disability. Indeed, several studies have shown that the routine use of radiographs in the care of low back pain may result in worse outcomes than without their use.
2. Do not perform repeat imaging to monitor patients’ progress.
With few exceptions (e.g., the long-term management of idiopathic scoliosis) radiographic findings should not be used as outcome measures for low-back pain. There is currently no data available to support a relationship between changes in alignment or other structural characteristics and patient improvement. This practice increases costs, exposes patients unnecessarily to ionizing radiation and may distract from more meaningful outcomes. Furthermore, there is no known correlation between performing routine or repeat imaging studies to monitor a patient’s condition and improved clinical outcomes or meaningful changes in patient management. Repeat imaging is appropriate only if strong clinical indications exist, such as a major change in diagnosis, documented worsening of symptoms or significant progression of disease. Failure to respond to treatment is not an indication for repeat imaging.
3. Avoid protracted use of passive or palliative physical therapeutic modalities for low-back pain disorders unless they support the goal(s) of an active treatment plan.
Passive physical therapeutic modalities are defined as those interventions applied to a patient with no active participation on the part of the patient. These include heat, cold, electrical stimulation and ultrasound. These passive therapies can play an important role in facilitating patient participation in an active treatment program. However, the use of passive therapies untethered to the goal of increasing physical activity can be harmful, as it can lead to patient inactivity, prolonged recovery and increased costs. For any patient with a low-back pain disorder to achieve an optimal clinical outcome, an essential element is to restore, maintain or increase the level of physical activity. The evidence demonstrates that both general physical activity (e.g., walking, jogging, biking) and specific exercise regimens are effective in treating and preventing low-back pain and may lead to better outcomes when combined with spinal manipulation.
4. Do not provide long-term pain management without a psychosocial screening or assessment.
There is a high probability that any person with a chronic pain syndrome has a concomitant psychological disorder, most notably depression and/or anxiety. The relationship between chronic pain and depression/anxiety is well established. The causal arrow between pain and these disorders can point in either direction and over time may form a positive feedback loop between these two elements. Screening tools are available that will aid in the detection of potential depression/anxiety, and, when indicated, a referral may be most appropriate for more extensive evaluation and treatment. In addition, lesser psychological factors such as catastrophizing and fear avoidance behavior may interfere with a patient’s recovery and should be recognized by the clinician. Recognizing indicators of patient psychosocial health behavioral factors can affect a patient’s recovery and/or compliance with treatment and may decrease the risk of developing chronic illness/pain. Tools such as StarTBack 9 screening tool, PHQ-9 depression scale and the Fear Avoidance Belief Questionnaire are examples.
5. Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.
While there may be limited benefit in the short term, the prolonged use of lumbar supports is not supported by the literature for the treatment or prevention of low-back pain. Numerous systematic reviews have found limited to no value for their use in this context. The literature clearly demonstrates that such passive therapies are contrary to the currently accepted central principle of low-back pain care, which is that the patient must engage in an active rehabilitative regimen to achieve the best outcomes.
How This List Was Created
The American Chiropractic Association (ACA) utilized its Committee on Quality Assurance and Accountability (CQAA) to serve as an expert task force of doctors of chiropractic (DCs) to identify areas/items common to the practice of chiropractic for which recommendations were supported by clinical research and would result in high-value, cost-effective services and improved patient outcomes. A literature search was conducted and the task force collaboratively identified a draft list of six recommendations based upon established Choosing Wisely® criteria. The list was submitted to the ACA Board of Governors for initial review. After further refinement, the final list of five strategies was selected, submitted to and approved by the ACA Board of Governors.
Printable PDF with sources
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