Physical Medicine and Rehabilitation

Six Tests and Treatments to Question

by
Canadian Association of Physical Medicine and Rehabilitation
Last updated: September 2022

Don't order urine cultures or treat bacteriuria in persons with neurogenic bladder unless there are signs or symptoms of urinary tract infection.
1

Patients with spinal cord injury and other conditions that cause neurogenic bladder are at higher risk of developing complications of urinary tract infections, which can drive over-investigation and over-treatment. However, several high-quality studies have demonstrated that screening for and treating asymptomatic bacteriuria (outside of pregnancy and urologic procedures) increase the risk of microbial resistance and the emergence of symptomatic urinary tract infection (UTI). Clinicians should order urine cultures if there are signs and symptoms of a urinary tract infection. Clinicians should treat suspected UTI only with evidence bacteriuria with accompanying signs or symptoms.

Sources:

Craven BC, Alavinia SM, Gajewski JB, et al. Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project. J Spinal Cord Med. 2019 Oct;42(sup1):205-214. PMID: 31573440. https://pubmed.ncbi.nlm.nih.gov/31573440/

Kavanagh A, Baverstock R, Campeau L, et al. Canadian Urological Association guideline: Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Executive summary. Can Urol Assoc J. 2019;13(6):156-165. PMID: 30763235. https://pubmed.ncbi.nlm.nih.gov/30763235/
Don't recommend more than a brief period of physical and cognitive rest (i.e., 24-48 hours) before encouraging patients to gradually resume activity following concussion (mild traumatic brain injury).
2

There is insufficient evidence that a mandatory period of physical and cognitive rest following concussion (mild traumatic brain injury) minimizes concussion symptoms or promotes recovery. Patients, rather, should be counselled to return to normal activity as tolerated after a brief period of rest. Athletes should return to competitive sport on a graduated basis following concussion.

Sources:

McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847. Epub 2017 Apr 26. PMID: 28446457. https://pubmed.ncbi.nlm.nih.gov/28446457/

Marshall S, Bayley M, McCullagh S, et al. Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: 3rd Edition (for Adults 18+ years of age). Toronto, ON: Ontario Neurotrauma Foundation, 2018. https://braininjuryguidelines.org/concussion/fileadmin/pdf/Concussion_guideline_3rd_edition_final.pdf
Don't start opioid analgesics for management of chronic noncancer pain without thorough trials of non-opioid medications and non-pharmacologic treatments.
3

There is insufficient evidence that opioids for chronic pain management improves symptoms or enhances function. Conversely, opioid usage is associated with side effects and carries substantial risks, including of dependency and poisoning. Opioids for chronic noncancer pain should be initiated only after other nonopioid options have been exhausted. Prescribers are encouraged to escalate opioid doses judiciously with a view to stabilizing patients on the lowest effective dose that will enable patients to achieve their treatment goals. Moreover, opioids should be discontinued if clinically important goals, such as reduction in pain or improved function, are not achieved.

Sources:

Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845. https://pubmed.ncbi.nlm.nih.gov/28483845/

Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276-86. PMID: 25581257. https://pubmed.ncbi.nlm.nih.gov/25581257/

Health Quality Ontario. Opioid Prescribing for Chronic Pain [Internet]. 2018 [cited 2022 June 1]. https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-opioid-chronic-pain-clinician-guide-en.pdf
Don't order diagnostic imaging for low back pain without red flag signs or symptoms.
4

In the absence of red flags, most patients with acute low back pain will improve, and do not require imaging for diagnosis. Patients without red flags should be treated with at least a 4-6-week trial of conservative management. Red flags for low back pain include but are not limited to severe or progressive neurologic deficit, cauda equina syndrome, or suspected cancer, infection, compression fracture, epidural abscess, or hematoma.

Sources:

Canadian Association of Radiologists. 2012 CAR Diagnostic Imaging Referral Guidelines [Internet]. 2012 [cited 2022 June 1]. https://car.ca/patient-care/referral-guidelines/

Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918. https://pubmed.ncbi.nlm.nih.gov/19200918/
Don’t order repeat injections without evaluating the individual’s response to previous injections.
5

Interventional pain treatments can include injections in or around joints, bursae, nerves, and tendons, with or without the guidance of imaging modalities such as fluoroscopy or ultrasound. Risks and side effects are uncommon but can be serious. Injections should only be repeated if previous injections have demonstrably resulted in the achievement of goals such as reduction of pain or functional improvement.

Sources:

Health Quality Ontario. Chronic Pain: Care for Adults, Adolescents, and Children (Updated Draft) [Internet]. 2018 [cited 2022 June 2]. https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-chronic-pain-clinical-guide-1810-en.pdf

Health Quality Ontario. Chronic Pain: Care for Adults, Adolescents, and Children (Updated Draft) [Internet]. 2018 [cited 2022 June 2].
Don't recommend carpal tunnel release without electrodiagnostic studies or ultrasound to confirm the diagnosis of nerve entrapment.
6

Carpal tunnel release is a highly effective treatment for Carpal Tunnel Syndrome (CTS). Clinicians considering referral for surgical management should be aware that good surgical outcome is best correlated with a combination of positive clinical and positive electrodiagnostic studies (EDx). More recently, ultrasound has also been established as an accurate test in diagnosing CTS. Clinical tests together with a supportive diagnostic investigation, such as EDx or ultrasound, have a better association with surgical outcome than either alone. Surgery for CTS is typically reserved for patients who fail conservative measures, such as an adequate trial of splinting.

Sources:

Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012 Aug;46(2):287-93. PMID: 22806381. https://pubmed.ncbi.nlm.nih.gov/22806381/

Basiri K, et al. Practical approach to electrodiagnosis of the carpal tunnel syndrome: A review. Adv Biomed Res. 2015 Feb 17;4:50. PMID: 25802819. https://pubmed.ncbi.nlm.nih.gov/25802819/

Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40. PMID: 11410921. https://pubmed.ncbi.nlm.nih.gov/11410921/
How the list was created

The Canadian Association of Physical Medicine and Rehabilitation (CAPM&R) established its Choosing Wisely Canada Top 6 recommendations as a result of a one-year long process. Special Interest Groups (SIGs) were asked to propose relevant items to be considered for Choosing Wisely Canada. As a result, 23 items were refined and distributed to all 385 CAPM&R members for ranking. The CAPM&R executive committee chose a final list of six items from the most highly ranked items on the national survey. At the May 2016 annual CAPM&R meeting, the six items with summary statements and literature reviews were presented to the CAPM&R membership and ultimately approved.

September 2022 update: Dr. Chris Fortin and Dr. Wendy Levinson presented a Webinar on the Choosing Wisely movement in October 2021, which included a review of existing PM&R recommendations and a survey that canvassed attendees’ familiarity with them and their ideas for updates. Thereafter, a committee consisting of three staff physiatrists and a PM&R resident from different academic centres was formed. They surveyed general CaPM&R membership and used the results to draft updated recommendations. These were presented to the CaPM&R special interest group (SIG) in Quality Improvement and Patient Safety in early 2022. They then consulted individual SIG group leads based on the subject matter of the individual items. The updated list was finalized with added rationales and references. The new items were approved by the CaPM&R Executive Committee in August 2022.