I have many opportunities to speak about the Mechanical Diagnosis & Therapy (MDT) paradigm and its literature support. But recently, I’ve had some unique, very worthwhile, and pleasurable presentations.

Last month, I traveled HarriHamalainen2015to Helsinki, Finland at the invitation of Dr. Harri Hamalainen, the Chair of the Dept. of Physical Medicine and Rehab in Helsinki’s biggest hospital.  I learned while there it is the biggest hospital in Europe. I spoke to a mix of family practice and PM&R docs about the role MDT care could play in transforming spine care in Helsinki.

Dr. Hamalainen’s vision is to have family physicians and MDT practitioners across Helsinki together screen and treat all painful spinal disorders before sending the few failures to his Dept. for further evaluation. That’s an amazing vision that is directly related to Sinikka Kilpikoski’s (McKenzie Institute’s faculty member) dedication and hard work over many years promoting MDT in Finland and establishing a trusting relationship with Dr. Hamalainen.  That vision, if realized, would truly shift the dominance of spine care from the specialists to primary care while greatly improving the quality while dramatically reducing the cost of care.

I also led an enjoyable session with PTs, most of whom were MDT-trained.  We discussed a host of relevant topics that hopefully provided a greater sense of the future immense role of MDT in managing musculoskeletal disorders.

In Sept, I also had th2015OverDxConfNIHe opportunity to speak at the “Preventing Over-Diagnosis” conference held at the National Institute of Health in Bethesda, MD.  Imagine an entire conference focused on the challenges of making an accurate diagnosis! Three hundred-fifty international attendees came with a focus on the need to make better diagnoses across all of health care.

This was their third annual meeting and they’ve never had any presentations focused on the huge problem of diagnosis in spine care, that is till I showed up.  I presented for 20 min. in a general session and then had a 90 min. symposium later that same day, attended by about thirty from all over theglobe.  As a result, I’m now corresponding with a number of attendees, including a researcher from Nigeria who wants to know more.

More recently, I participated in a 3-day think-rank entitled “State-of-the-Art in Spine Control II” organized by Paul Hodges, the Australian motor control researcher.  There were 25 of us that spent those days in the spectacular presidential suite at the Chicago Hilton where we all presenteHodgesForum2d for 20 min. to the entire group, five speakers each half-day, followed by 90-min. of discussion. The latter was the best part.

The group included well-known “experts”: Julie Hides, Shirley Sahrmann, Julie Fritz, Allan Breen, Linda VanDillen, Greg Kawchuk, Diane Lee, Chris Maher, Paul Hodges, Heidi Prather and a host of basic scientists from around the world who I had never met before. Peter O’Sullivan and Lorimer Moseley were to attend but, sadly, had to cancel at the last minute.

I, of course, presented MDT and its literature support. But in keeping with the motor control theme of the forum, I emphasized MDT’s strong focus on ‘posture correction” when treating the very common reducible derangement. Sitting and standing erectly obviously involves basic ‘motor control” but with no need to examine or even discuss the role of individual muscles nor monitor their change over time. Posture correction is conceptually very simple and a critical feature of MDT treatment intended primarily to avoid mechanically loading the pain-generator in the aggravating direction when not exercising in the preferred direction. I asked this group of motor control experts how they would ideally help patients with posture correction.  Julie Fritz, Shirley Sahrmann, and Julie Hides responded but offered no specific insight in how to facilitate posture correction in terms of specific strengthening routines.

But perhaps the best part is still to come.  Each half-day speaking group will be co-authoring an article to be published in a special issue of the Journal of Orthopedic and Sports Physical Therapy in 2016.  My co-authors will be Shirley Sahrmann, Julie Hides, Diane Lee, and Heidi Prather.  We’ll explore both the similarities and differences of each other’s clinical approaches.  Preliminary discussions with Julie and Shirley revealed a number of commonalities, including our focus on diagnosing the nociceptive-mechanical portion of each patient’s presentation, the need for reliable sub-grouping, seeking pain relief, patient-centered care, correcting posture, prioritizing treating a directional preference, as well as patient education aimed at improving long-term self-care. It will be still be a challenging article to write but I’m sure it will help a global PT readership appreciate the unifying features of these seemingly diverse, even competitive, approaches. I’ll keep my blog readers updated on the progress of this process.

As always, please share your thoughts as well as pose any questions that come to mind.

I have been interacting with and attempting to teach physicians for the past 30 years about the methods, value, growing evidence, and clinical implications of the Mechanical Diagnosis & Therapy (MDT) form of care.  Guideline panels continue to ignore the substantial evidence validating the existence of LBP subgroups in favor of their near-total attention on randomized trials (RCTs) that target the non-specific symptom of low back pain (LBP).

Shared decision-making content “experts” are no different, choosing to ignore an option that every surgical candidate would likely jump at: taking 2-3 appointments for an MDT evaluation with a 50% chance of rapid and complete recovery without surgery.

The rate of progress in converting minds to even consider incorporating the MDT paradigm of care into one’s clinical pathways can be depressing at times.

Theories attempting to explain this reluctance to shift to MDT care include a resistance to change longstanding habits and patterns learned from mentors, even if there might be patient benefit in doing so.  There’s also the economic bias based on a concern that higher recovery rates and speedier recoveries might undermine revenue from “the hammer” wielder so focused on finding “a nail” rather than a patient-centric solution.

Tolstoy has a grasp on the human condition and this explanation when he states (I paraphrase from “What is art?” Leo Graf Tolstoy, 2014:124): “Most men who are capable of understanding difficult scientific, mathematical, or philosophic problems can very seldom discern even the simplest and most obvious truth if it obliges them to admit the falsity of conclusions they have formed, of which they are proud, which they have taught to others, and on which they have built their lives.”

I’ve always characterized his view as simple “pride and ego”.

In my experience, Tolstoy’s statement rings true for most spine care specialists, both surgical and non-surgical.  So many problems are made unnecessarily complex because of mis-diagnosis that is commonly and simply solved: making a mechanical diagnosis using MDT methods of care. But this is apparently just too simple for most spine specialists to grasp, acknowledge, and implement.

So who is ready to hear this MDT message? I believe it is only those in pain who would themselves benefit from high quality care at a lower price.  They essentially comprise two types: patients experiencing the actual symptom of pain and related impairment, and self-insured employers who suffer with the economic pain related to their employees being regularly mis-diagnosed in the community and consequently mis- and over-treated, leading to excessive direct and indirect costs.  Comparatively speaking, spine specialists are not in pain.  But they make a generous living by both providing services to those in physical pain and by accepting compensation from those in economic pain.

But there is one other clinical group that tends to truly have their patients’ best interests at heart without significant financial conflict of interest. They include family physicians, nurse practitioners, physicians’ assistants, internists, pediatricians, gynecologists, and urgicare and ER docs.  But even they have their established care pathways that enable them to efficiently manage their patients within the fast pace and short appointment times of their daily practice. Unfortunately, those pathways far too often include: 1-an early, often misleading MRI; 2-a specialist referral that is not always helpful, can even be detrimental while greatly increasing the cost of care; and 3-a narcotic prescription to provide some pain relief for their patient.

I am currently working on a book for primary care-givers that will introduce the idea of a primary “team-based” approach to musculoskeletal care, characterized by adding MDT expertise to their team.  As with my previous books(1, 2), this one will focus on the “Why” of MDT.  The “How” of individualized patient care is covered well in Robin McKenzie’s textbooks and his “Treat Your Own” series.

I’ll keep everyone posted on my progress with this project and its availability.

As always, please share your thoughts, this time about reaching doctors with the MDT message, as well as any questions that come to mind.

1. Donelson R. Rapidly reversible low back pain: an evidence-based pathway to widespread recoveries and savings. Hanover, NH: SelfCare First, LLC; 2007. FIND ON http://www.amazon.com

2. Donelson R. Solving the mystery: the key to rapid recoveries from back and neck pain. Hanover, NH: SelfCare First, LLC; 2010.  FIND ON http://www.amazon.com

In a recent online conversation with other spine care specialists, the topic of “central pain processing” arose as a common explanation for chronic low back pain (CLBP).  Many believe such a phenomenon of pain shifting from a nociceptive structural origin to a spinal cord (central) generator is a common occurrence and explains a great deal of CLBP. I responded with the following posting.

“I can’t resist jumping in on this discussion of CLBP.  “Chronic” merely means it has been around for awhile – the actual duration definition varies. For some of those patients, the label “central pain processing” (CPP) may apply. But who are they? Unless we can identify them, we have no hope of delivering effective care. So how do we RELIABLY identify who they are and, just as importantly, WHO THEY AREN’T? To answer those questions, we need to take a broader look at CLBP.

One posting points out that we often can’t visualize a structural pain generator causing CLBP. It is then very common to incorrectly assume that there is none and look for an alternative explanation for the persisting pain. But there was also no generator visible when the pain was acute and presumed to be nociceptive, i.e. structural. Many then incorrectly assume that chronic patients no longer have nociceptive pain, as though that type of pain generator always recovers in 6 weeks or so. But that’s just not true.

Hippocrates said: “Healing is a matter of time, but it is also a matter of opportunity.” An injury or disorder that is never given the opportunity to heal will persist. A cut on your hand that is frequently traumatized does not heal. It needs protection to allow good healing. Likewise, a sprained ankle or fractured bone that is continually stressed and re-injured does not heal. These things have an expected healing time, but they often do not heal if not given the opportunity.

Why would LBP be any different? The prime example are those who are found to have a directional preference. Their pain centralizes and abolishes and recovery is typically fairly fast and quite predictable, despite the chronicity of their pain. This can happen many months, sometimes even years, after the onset of their pain. They were perfectly capable of healing long, long ago, but the pain generator was never provided the opportunity to recover. It wasn’t until their directional mechanics were finally explored that their pain generator’s directional preference was identified and was finally addressed. Only then, for the first time, was the generator provided “the opportunity” to heal. These folks then recover quite well.

Multiple published data report that this dir. pref. subgroup makes up 50% of the CLBP population. That’s remarkable and should get the attention of every clinician who cares for LBP. It may be a higher or lower percentage in different practices depending on: 1-other characteristics of that population, like the presence or absence of secondary gain, and 2-the training, skills and experience of the examining clinician.

This large CLBP subgroup with a dir. pref. definitely does NOT have a problem with “central pain processing”. CPP pain would not centralize and abolish rapidly with the performance of a single direction of repeated end-range spinal loading movements.

So we need to be cautious in how we characterize CLBP. There are indeed subgroups. The beauty of the dir. pref. subgroup is that its members and non-members can both be fairly easily and reliably identified. Members can be treated very effectively while non-members need further evaluation and other forms of treatment.

Only non-members of the dir. pref. subgroup should be considered to possibly belong in the CPP subgroup. The CPP subgroup is likely much smaller than many envision.”

Please share your thoughts with me and whatever questions come to mind.

Of course, low back pain (LBP) isn’t a diagnosis.  It’s a symptom, and a very non-specific (NS) symptom at that.  Unfortunately, the lumbar spine, with all its complexity, has a very limited vocabulary with which to express itself when some part of it is in trouble.  So LBP can be the result of many different pathologies for which there obviously is no single effective treatment.  Yet we keep conducting research trying to find the best treatment for the 85% or more with this NS symptom.

Let’s for a moment consider fever, which long ago was another NS symptom, but a very serious one.  For centuries, millions with a fever ended up dying, many during pandemics, many others as more isolated cases.  Many treatments were desperately tried hoping to save lives.  The breakthrough came when the microscope was invented that revealed microbes causing what became known as infection.  Culturing techniques and other diagnostic innovations eventually led to the accidental discovery of penicillin and other very effective antibiotics based on their specificity for each microbe.

If the scientists and physicians of that day had simply searched for the best treatment for NS fever, people would have continued dying. Instead, it was a breakthrough in diagnostics that led to saving millions of lives from infections.

What if people were dying from NS-LBP?  How long would we persist in searching for the best treatment for NS-LBP? Wouldn’t we be far more focused on learning something about its cause?

While many LBP treatments likely have value for some types of LBP, they are certainly not one-size-fits-all-treatments as they are commonly delivered and portrayed. Would abdominal or chest pain treatment be dictated primarily by the clinician the patient selects for care? Does every LBP patient simply look like a nail for the hammer(s) each clinician is trained to use?

Instead, as with fever, shouldn’t LBP researchers be focused on learning more about the cause of LBP? Unfortunately our best imaging technology has failed to help us find structural causes.  Knowing that, the Cochrane Back Review Group wrote in 1998: “There is urgent need for good ideas about how to identify homogeneous subgroups. The efficacy of interventions in the subgroups should be studied in randomized controlled trials.”(1)  Their “urgent need” was seventeen years ago!

Five years later, they wrote again: “systematic reviews on the efficacy of preventive and therapeutic interventions can never provide an adequate basis for clinical guidelines.  We clearly need additional systematic reviews of etiological, diagnostic, and prognostic studies.  Only then can the guidelines hope to offer an evidence-based answer to the “Holy Grail”-type questions, such as “which interventions are most effective for which patients?”(2)

Consider further two surveys (1998 and 2013) of international LBP researchers.(3, 4) Both reported that the #1 research priority was: “Can different varieties or subgroups of LBP be identified and, if they can, what criteria can be used to differentiate among them?” One listed twenty and the other twenty-five top research priorities.  The focus of most RCTs and LBP guidelines, i.e.“finding the best treatment for NS-LBP”, was of such low value to the responders that it didn’t appear on either list.

Little clinical research and no LBP clinical guidelines to date offer any insight into which interventions are most effective for which patients.  They contribute little or nothing to the quality of our decision-making when treating an individual with LBP. When will we get the message and shift our research focus?

Identifying and validating subgroups needs to become our top research focus.  But that requires more than RCTs. A new research paradigm(5) is needed that begins with reliability studies to demonstrate that both subgroup members and non-members can be reliably identified. A reliably identified subgroup then feeds subgroup-specific observational cohorts to identify potentially effective treatments.  Only then can the time, effort, and expense of conducting an RCT be justified in hopes of validating that subgroup by identifying a standardized, predictably effective treatment.

Ironically, guidelines have yet to acknowledge the considerable research over the past twenty-five years that has successfully identified and validated some LBP subgroups, most based on clusters of clinical findings. One with considerable support is the “derangement” subgroup in whom “pain centralization” and a “directional preference” are reliably elicited during a standardized baseline mechanical examination. Subgroup-specific observational cohorts, RCTs, and systematic reviews have validated this mechanical diagnosis. But these studies are routinely overlooked by most clinicians, researchers, and every guideline-to-date, constrained by their tunnel vision on finding the best treatment for NS-LBP.

What a great concept: matching treatments to individual patient characteristics!! Sorta like selecting an antibiotic for a specific microbe instead of treating a fever with blood letting.

Of course, for every validated LBP subgroup, the percentage considered to have NS-LBP decreases…..and that’s a good thing.  So why do funders keep funding RCTs focused on NS-LBP?  It was Einstein who defined insanity as “doing the same thing over and over again and expecting different results.”

In summary, it’s deeply troubling that 1-our lack of progress in solving LBP, 2-the large numbers who are disabled by low back conditions, and 3-the increasing amount we spend each year for ineffective care, are insufficient motivation to bring change in either the conventional LBP research paradigm or the focus of clinical guidelines.

How quickly would we change our research focus if people were dying from LBP?

References
1. Bouter L, van Tulder M, Koes B. Methodologic issues in low back pain research in primary care. Spine. 1998;23(18):2014-20.
2. Bouter L, Pennick V, Bombardier C. Cochrane back review group. Spine. 2003;28(12):1215-8.
3. Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain:  reexamining priorities. Spine. 1998;23(18):1992-6.
4. Costa L, Koes B, Pransky P, Borkan J, Maher C, Smeets R. Primary care research priorities in low back pain: an update. Spine. 2013;38:148–56.
5. Spratt K. Statistical relevance. In: D.F. Fardon ea, Editors, editor. Orthopaedic Knowledge Update: Spine 2. 2nd ed. Rosemont, Illinois: The American Academy of Orthopaedic Surgeons; 2002. p. 497-505.

Please share your thoughts with me and ask whatever questions come to mind.

I recently reviewed a randomized clinical trial (RCT) that got my attention. Randomizing low back as well as cervical pain patients to either surgery or non-surgery has become a common and attractive study design ever since the National Institute of Health justified funding the SPORT trial ten years ago to the tune of $18 million. After all, isn’t that a crucial decision in spine care worthy of an $18 million investment – whether to operate or treat conservatively?

But there are inherent problems with this study design. It simply isn’t generalizable to real-life practice because non-surgical care always precedes surgery. Non-surgical care and surgery are sequential, not concurrent. Surgery isn’t indicated until non-surgical care has been exhausted and failed to adequately help the patient. Obviously no patient wants surgery if able to recover without it.

The real life decision is when to operate, not which is better? Surgery is never a good choice if there is still a non-surgical treatment worthy of trial.

So there are two related problems with investigating this research question of which is better. First, what constitutes sufficient failed non-surgical care that qualifies a patient to be a surgical candidate and therefore a candidate for such a study?

Consider that primary care physicians commonly refer to spine surgeons simply because the patient has a radiculopathy and needs an MRI, or already has an MRI showing a herniated disc. The surgeon is viewed as the spine expert who is better able to guide care, including appropriate diagnostics, non-surgical care, and then perhaps even surgery. A patient should not be a surgical candidate simply because (s)he is referred to a surgeon or because a certain amount of time has passed. These were the two inclusion criteria defining sufficient non-surgical care in this recent RCT I reviewed.

But there’s a second related problem. A critical question in these studies is never asked: what conservative care has each patient had prior to randomization? It’s never asked because it’s often not asked by spine surgeons during their routine patient care who assume that the referring doc has already exhausted conservative care.  But surgeons should evaluate whether each patient has had sufficient, or the right form(s) of, non-surgical care before recommending surgery.  Again, that aspect of each patient’s history is typically ignored but should be part of the baseline data gathered in all these studies.

Without that pre-study non-surgical care information, some, perhaps many, are randomized to conservative care that had previously failed to help. Would we randomize one of these subjects to surgery who had previously undergone failed surgery? No, we’d likely exclude them altogether, but we’d at least be sure they’re not randomized to the same surgical procedure that has already failed. So to avoid randomizing subjects to care that has already failed, RCTs need to document the type of conservative care each patient had undergone prior to randomization.  But again, if there is more conservative care that might be helpful, why are they even considered a surgical candidate to meet inclusion criteria?

Meanwhile, as has been posted prominently in my blogs, there is strong evidence that eliciting the two clinical findings of directional preference and pain centralization indicates that a patient is NOT a surgical candidate because recovery is so predictable with appropriate directional treatment. These two findings are commonly identified across the a wide spectrum of painful spinal conditions: acutes, chronics, axial and referred pain, radiculopathies, stenotics with pseudo-claudication, spondyloytic and -listhesis patients.

The goal of these RCTs is presumably to improve surgical decision-making. But to avoid a variety of unnecessary surgery, every spinal pain patient should undergo a mechanical evaluation that tests for directional preference and pain centralization before considering surgery. Otherwise, surgery is commonly performed for patients with an undiscovered directional preference.  Of course, that exam needs to be performed by a well-trained McKenzie clinician to determine if the disorder is mechanically reversible.

So tell me below what you think or ask what questions you have.

Two weeks ago, I posted my claim and rationale that Robin McKenzie’s serendipitous observation of “directional preference” more than 50 years ago was the greatest discovery in the history of low back and neck pain management.

But for some, it was my prior posting about the natural history (NH) of low back pain (LBP) that was especially enlightening. To review, conventional thinking is that a high percentage of LBP recovers on its own if left alone and especially if aided by maintaining daily activities as much as possible despite the pain. A further NH belief is that recurrent episodes, while very common, deserve no particular attention since they, like the original episode, also have a highly favorable prognosis for recovery. That line of thought likens LBP episodes to the common cold: one bout typically does not affect the next.

In contrast, my posting cited data that recoveries from LBP episodes are far less common than guidelines portray them to be. Further, there’s ample data indicating that recurrences often worsen over time and eventually simply don’t recover, providing a common, but rarely acknowledged, pathway to chronic pain. Finally, I proposed that the high prevalence of a directional preference across the LBP population serves as a very plausible explanation for why recurrent episodes and their recoveries are both so common.

One reader found this NH posting to be particularly enlightening and commented: “This is the best, simplest, most brilliant elucidation of the natural history of back pain.….Reading this post, I feel like I’ve just read Copernicus on how the solar system works.”

That’s quite a statement! He realizes the fundamental importance of an accurate understanding of LBP’s natural history plus how the majority of LBP behaves with a directional preference, whether a patient is seeking care or not.

Hopefully more spine care clinicians and other stakeholders will read, or perhaps re-read, these two postings to gain some perspective and insight that will likely challenge their views of this huge health care dilemma.

As always, I welcome your thoughts and questions. Please leave a comment or question below.

For centuries, many with a fever died before we ever knew what an infection was. Fever was often attributed in those days to things like immorality or weakness of faith.  But with so many dying, a wide range of treatments were desperately tried.

In hindsight, there is little doubt that the cause of fever and associated deaths across those centuries was commonly an infection.  But not until diagnostic innovations like the microscope, culturing techniques, and sensitivity testing once antibiotics were invented could a very precise diagnosis of infection be made, followed by the delivery of what became predictably effective antibiotic treatment.

Similarly, low back pain (LBP) and neck pain (NP) have been described throughout the history of mankind.  Hippocrates (c. 460 BCE – c. 370 BCE) was the first to use a term for sciatic pain and low back pain. Through the medieval period, folk medicine practitioners provided a wide range of treatments for back pain to address what they believed were bad spirits, not unlike the early theories about fever.  A psychosocial label seems to be a common default explanation when there is an inability to make a clear medical diagnosis.

Treatments included a diverse array of non-surgical methods until Mixter and Barr performed the first surgery in 1938 to remove some herniated nucleus pulposus.  Since then, both surgical and non-surgical decision-making and treatment remain highly variable and drive very expensive care tied directly to each care provider’s educational background and practice preferences.

Yet even today, it is commonly believed that the underlying diagnosis for these non-specific symptoms of LBP and NP is unknown in 85% of patients with a common belief that psychosocial issues play a prominent role when pain persists.

Directional Preference: the greatest discovery in the history of LBP?

Though the term “directional preference” (DP) was not introduced until 1991 (1), that clinical phenomenon was first observed by Robin McKenzie in the mid-1950s.  Since then, thousands of healthcare practitioners worldwide, mostly physical therapists, have been trained in McKenzie’s methods of clinical evaluation (also known as Mechanical Diagnosis & Therapy or MDT) by completing the educational curriculum and credentialing process offered by the McKenzie Institute International.

Such a high level of interest in this paradigm of care stems directly from the importance and value of identifying DP.   Quite simply, a DP found during an MDT evaluation identifies that the underlying pain-generator is “rapidly reversible“(2) and can be corrected in most cases by some simple exercises and posture modifications that can be performed entirely by the individual experiencing the pain.

Why is DP the greatest discovery in LBP history?

After centuries of having little insight into and no solution for these non-specific symptoms, there is now extensive documentation (2) that validates the importance of DP.  This documentation reports that:

  • the pain-generator for the majority with LBP and NP has a DP: 70-89% of recent-onset pain and at least 50% in those with chronic symptoms.
  • these patients can correct their own problem using the findings of this simple, inexpensive, safe, non-invasive diagnostic process.
  • since there is no need for invasive care, there is no need to identify the anatomic pain source nor to pursue any imaging or EMGs in this very large subgroup.
  • there is no need for medications, prolonged physical therapy or chiropractic care, ER visits, specialty referrals, injections, or surgery.
  • to achieve their recovery, these patients first learn how to eliminate their own symptoms, then how to prevent them from returning, and finally how to prevent future episodes by independently implementing the same self-treatment strategies either proactively or else promptly in reaction to any symptom or sign of a recurrence.

In many studies, DP has been tied to a pain-generating intervertebral disc disorder(2), whether the pain is primarily axial or tied to nerve root compression.  In either case, and regardless of whether the pain is acute or chronic, and regardless of what prior treatments have already been unsuccessful, a DP finding has an excellent prognosis if treated with matching directional strategies.

Given the centuries, including the last 50 years and the present, of how poorly LBP and NP have been managed, these are astonishing and game-changing facts. This DP discovery means that only 10-15% of patients still deserve the label of “non-specific” LBP or NP. Rather, the pain for the great majority with a DP appears to be directly tied to disc pathology.

So just as victims of fever across many centuries never had the benefit of diagnosing their infection and receiving specific antibiotic therapy, neither did LBP and NP victims have access to MDT diagnostics that would have identified the reversibility of their pain source.  Just what the microscope did for diagnosing the cause of most fever, Robin McKenzie’s diagnostic innovation dramatically contributed to the understanding and successful management of these very common and very expensive spinal disorders.

The tragedy is that, more than 50 years after McKenzie’s discovery, and despite the extensive DP publications over the past 25 years, most LBP and NP patients are still deprived by their doctors of the opportunity to undergo this MDT evaluation.  Most have a rapidly reversible disorder that is routinely undiscovered and routinely mis- or over-treated.  There’s also no reason to believe that most LBP and NP in the decades to come will not have a DP, whether or not it is discovered during each patient’s clinical evaluation.

The only remaining question is how long will today’s spine specialists remain fixed on their current status quo of care that appears to serve their own clinical preferences more than their own patients.  I believe clinicians get away with continuing their self-serving care preferences because, unlike treating fever, patients with LBP and NP aren’t dying if incorrectly treated.

As always, I welcome your thoughts and questions. Please leave a comment or question below.

1. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to repeated end-range sagittal spinal motion: a prospective, randomized, multi-centered trial. Spine. 1991;16(6S):206-12.

2. Donelson R. Rapidly reversible low back pain: an evidence-based pathway to widespread recoveries and savings. Hanover, NH: SelfCare First, LLC; 2007.

It is widely accepted that the natural history of low back pain (LBP) is highly favorable, yet we have little understanding as to why so many recover on their own. Is it merely the “tincture of time” that permits LBP to just “run its course”, like the common cold? Or is there something specific about the underlying LBP-generators themselves that allows them to recover so frequently, even without formal treatment? And after recovery, why do episodes so often recur and then recover again, and again?

Consider that multiple studies report that the pain generator of 70-89% of acute LBP has a mechanical characteristic called a “directional preference” (DP). That means that one direction of bending/loading the spine consistently improves the generator by centralizing or even abolishing the pain while the opposite direction consistently worsens it.  The pain source has therefore been described as “rapidly reversible” depending on the direction of spinal bending.  DP is routinely revealed during a standardized mechanical examination known as “Mechanical Diagnosis & Therapy”. Of those with a DP, the great majority improve with lumbar extension testing/movements/positioning while worsening with flexion.

It is also noteworthy that a DP is often present and operative even if it is never tested or identified by this form of mechanical exam.  It often remains undiscovered yet fully operative.

Independent of this MDT form of exam, an unpublished survey a few years ago of 38 primary care docs inquired about any “activity instructions” they give their LBP patients. All 38 responders said they routinely instructed patients to: 1) pursue walking, 2) avoid lifting, and 3) avoid sitting in a slouched position. Further, 75% said they also instructed patients to avoid forward bending and sit-ups and to always sit erectly. Clearly they wanted their patients avoiding lumbar flexion and pursuing erectness.

Likely none of these PCPs were familiar with the notion of DP, despite its prominence in the spine literature. Further, LBP clinical guidelines provide no insight into “good” vs. “poor” activities to pursue. So where did these PCPs learn such uniform instructions?  I would submit they’ve been listening to their patients’ directional likes and dislikes or may have directly learned by monitoring how their own LBP behaved.

My thinking on this is supported by a second survey that asked 349 LBP care-seekers how their pain responded to seventeen common movements, positions, and activities, nine of which clearly required lumbar flexion and the other eight were all upright or erect items.(1) Remarkably, all 349 patients graded all nine flexion items as more aggravating to their LBP than the eight upright items, all of which were graded as more comfortable (p < 0.0001).  That’s an impressive result.

So both patients’ pain experience and PCPs’ activity instructions closely match the DP data produced when the pain-generator is directly mechanically tested using MDT methods.  Further, many studies report that excessive lumbar flexion brings on LBP(5) and then aggravates the pain once started.(2-4, 6-8) Other studies report that being erect, either walking or supported sitting (relative lumbar extension) often decreases the pain.(6, 8)  All these data reflect the mechanics of the underlying condition: most don’t like flexion and prefer more extension.

So when people recover “on their own”, allowing LBP’s natural history to play out, it appears that there may be more than the mere passage of time. As Hippocrates said: “Healing is a matter of time, but it is also a matter of opportunity.” How very true.

A simple skin laceration needs time to heal, but it also needs favorable circumstances: perhaps stitches, or at least a protective bandage and some disinfectant. Alternatively, spending that very same time pulling the cut apart, scratching or tearing at it, or getting it dirty, will greatly prolong or even prevent healing altogether. Such persisting trauma or insult can even create a far worse problem than the original cut.  So time, without the provision of opportunity, is wasteful, even detrimental.

It’s bewildering that this time/opportunity notion is unacknowledged by some spine experts who mistakenly assume that any physical cause of acute LBP will have healed by six weeks so any pain that persists thereafter must be due to some alternative generator independent of the initial healed physical pain source. They ignore the need for an opportunity to heal.

So why is the natural history of LBP so favorable? Realistically, just like the skin cut, lasting recovery of the underlying disorder needs both time and opportunity. But how does an individual provide this opportunity for recovery when the cause of the pain is unknown?

Human nature may hold the key to these recoveries. Ben Franklin put it this way: “We are first moved by pain, and the whole succeeding course of our lives is but one continuous series of actions with a view to be freed from it.”  We instinctively try to avoid or minimize pain.  Even without specific instructions, our own painful backs quickly teach us that bending, lifting, and prolonged slouched sitting aggravates our problem. So we of course avoid or minimize those activities and positions and learn that our pain is actually reduced by other positions and activities which we then pursue.   We sit taller, we minimize sitting, walk more, and avoid bending and lifting, all with the intent of helping ourselves recover.

In essence, clinical guidelines’ recommendations that patients return to activity as soon as possible obviously encourages spinal movement, walking, and less sitting or lying in bed in flexed positions.  This activity in turn provides a variety of spinal positions and activities that then reveals what each painful back likes and doesn’t like.  Patients quickly learn and naturally modify their day in order to have less pain. Less lumbar flexion and more extension provides the pain-generating pathology the opportunity it needs to recover.

More research is needed to investigate the highly favorable natural history of LBP. The current hypothesis, based on these preliminary data, is that so-called “spontaneous” recoveries are closely tied to the pain generator’s DP with pain easily reversed and abolished by honoring and responding to that DP.

As always, I welcome feedback and questions. Please click on “Like” if this was useful and enlightening, or “Leave a Comment” by clicking on “Comment” below.

1. Donelson R, McIntosh G, Hamilton H. Is it time to rethink the typical course of low back pain? Physical Medicine & Rehabilitation Journal. 2012;4:394–401.

2. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to repeated end-range sagittal spinal motion: a prospective, randomized, multi-centered trial. Spine. 1991;16(6S):206-12.

3. Larsen K, Weidick F, Leboeuf-Yde C. Can passive prone extensions of the back prevent back problems?  A randomized, controlled intervention trial of 314 military conscripts. Spine. 2002;27:2747-52.

4. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized controlled trial of exercise for low back pain. Spine. 2004;29(23):2593-602.

5. Lund T, Labriola M, Christensen K, Bültmann U, Villadsen E. Physical work environment risk factors for long term sickness absence: prospective findings among a cohort of 5357 employees in Denmark. British Medical Journal. 2006;332:449-52.

6. Snook S, Webster B, McGorry R, Fogleman M, McCann K. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion: a randomized controlled trial. Spine. 1998;23:2601-7.

7. Spratt K, Weinstein J, Lehmann T, Woody J, Syare H. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine. 1993;18(13):1839-49.

8. Williams M, Hawley J, McKenzie R, Van Wijmen P. A comparison of the effects of two sitting postures on back and referred pain. Spine. 1991;16(10):1185-91.

 

 

 

Health care resources are limited.  Squandering them on ineffective, unnecessary, even risky treatment is simply unacceptable.  Purchasers of care, especially self-insured employers, are challenged to determine where such waste occurs and find ways to avoid it.  But how does one determine what spending will be wasteful before spending the money?

In the care of musculoskeletal (MSk) disorders, avoiding these unnecessary costs is no longer merely an aspiration but a reality. That’s great news since MSk care is one of every employer’s most expensive health care domains.   An employer with 1,000 employees can spend close to $1 million on MSk care each year.  That means $25 M with 25,000 employees, etc.  

Two large payers’ unpublished claims data now show that utilizing one specific type of MSk evaluation results in a direct savings of nearly 50% of their MSk costs.  These data will be published in the near future. But that’s right – 50% of those costs prove to be not only unnecessary, but they’re identifiable before that money is spent. So that spending is preventable and the savings goes right to the company’s bottom line. And these findings appear to be generalizable to most employers.

But there’s more good news. Such rapid recoveries also proportionally reduce lost work-time and wage replacement costs. Patient satisfaction is naturally also very high since most would rather work than not work.

Some call the combination of improved quality care tied to cost savings the “holy grail” of health care.  Such real “value” supports the adage that high quality care is usually also less expensive.  When you then add high patient satisfaction, you have what I call “the health care trifecta”.

The key to producing these benefits is better diagnostics, specifically by reliably identifying valid subgroups for which there are standardized, predictably effective treatments.  Consider that one very large subgroup, if left unidentified, is routinely mis-treated and often worsens. Costs then significantly and unnecessarily mount due to imaging, extensive medications, injections, and even surgery.  Avoiding these interventions in this subgroup is all strongly supported in the scientific literature.

The challenge is that most care-givers don’t know about either these diagnostics or this reliability and validity literature.  For example, several studies confirm that a high percentage of patients undergoing expensive MRIs, injections, and even surgery actually have a very treatable condition using this form of inexpensive non-surgical care that so often results in rapid recoveries.  Again, the key for most employers is that these patients are identifiable before this unnecessary, ineffective care is undertaken.

Most physicians’ solution to the problem of an insufficient diagnosis to simply ignore it. They instead focus on providing the best, or their favorite, treatment while remaining largely ignorant to what is actually wrong with their patient.  But most stakeholders remain unaware of these diagnostics and instead continue their unfortunate focus on hundreds of studies that unsuccessfully attempt to determine the best treatment for various non-specific pains.

I’m intentionally omitting in this posting any description of the diagnostic procedures that have generated such savings.  The message of this posting is intended for employers and health plans as an alert to their opportunity to dramatically reduce their very high costs for MSk care.

As always, I welcome feedback and questions. Please click on “Like” if this was useful and enlightening, or “Leave a Comment” by clicking on “Comment” below.

My last post outlined Mark Bertolini’s three-point solution to fixing health care in the U.S. This CEO, President, and Chairman of Aetna advocates promoting evidence-based care starting with “big ticket” health care domains. Aetna currently has diabetes in its cross-hairs for improving cost-effective care.

His second initiative is to transition from a system of fee-for-service or volume-based to value-based reimbursement that rewards good outcomes. Finally he sees the need to re-structure the health care delivery system to enable access to those providers with outcomes documentation that they actually deliver superior care.

Bertolini says his three-point plan “attacks the entrenched establishment that profits from the existing inefficiencies.”  I agree.  Let me provide a real-life illustration.

No health care domain is more expensive and inefficient, and has more unwarranted variation in care, than spine and musculoskeletal management.  The estimated U.S. annual cost in 2004 was $840 billion for direct care and indirect lost wages.  That was nearly 8% of the U.S. GDP (U.S. Dept. of HHS, AHRQ, Medical Expenditures Panel Survey, 1996-2004). Further, there’s ample evidence that these costs have since continued to rise.

There is now substantial health plan and employer claims data documenting that a specific and unique mechanical form of clinically evaluating and diagnosing most musculoskeletal disorders (excluding fractures, dislocations and infections) can identify patient-specific non-pharm, non-invasive treatments that generate both rapid and long-term clinical recoveries. Such outstanding clinical outcomes should naturally be expected to generate significant savings which have indeed been documented in large payers’ claims data at more than 40% in direct costs and even greater indirect cost savings. These improvements include an 80% drop in the low back and neck pain recurrence rates (to <10%) in the year after treatment as well as a 97% patient satisfaction rate.

Patients’ excellent one-year clinical outcomes are also predictably reflected in the substantial drop in re-utilization of care after discharge which drives this large savings documented in payers’ claims data.  It is the documented long-term recoveries and this significant drop in recurrence rates that generate the greatest part of that savings due to the greatly decreased need for more complex and expensive diagnostic and therapeutic interventions.

I’ve coined the term “biomechanomics” to characterize all the clinical and economic benefits of implementing this specific evidence-based mechanical approach to musculoskeletal care.

To achieve these savings, this specific type of management must be rewarded and accessed utilizing Bertolini’s 2nd and 3rd strategies: value-based reimbursement and altering the delivery of care.

So the second key to these payers’ savings is the transitioning of reimbursement from a volume- to a value-based system. For them, this is no longer just some far-off aspiration, but an actual reality. A simple case-rate based on the value of the intervention to the payer works exceptionally well to access these specially-trained clinicians.  It is their advanced training and clinical expertise that provides the key to these outstanding clinical and economic outcomes, coupled with a robust internal quality assurance program that guarantees their delivery of these outcomes.

The further good news is that the alteration in the delivery of this form of care does not require long distance travel to access academic centers of excellence, cited as attractive to Bertolini for the definitive care of other expensive conditions.  Any delivery disruption will be minimal here as the number and availability of these specialized clinicians grows to where this service can be accessed in all cities, communities, and large workplaces, driven by value-based case-rate reimbursement that incentivizes growing numbers of clinicians to seek the required training that enables them to deliver these outcomes.

With the U.S. health care system spending an estimated $500 billion per year for non-fracture/dislocation/infectious musculoskeletal care, a fully-scaled 40% savings translates to a $2 trillion U.S. savings over a ten-year span.

So two essential questions surface: 1-what patient would not want to explore a high rate of safe, non-invasive, and usually rapid short- and long-term recovery with a 97% satisfaction rate? And, 2-what payer would not be attracted to a high percentage of happy recovered members or employees plus a 40% savings across such a huge and expensive health care domain whose costs otherwise will just keep growing?

Publication of these claims data and savings is expected in 2014. However, I would think the Bertolini’s of the health plan and employer world would want to explore this option sooner rather than later in their efforts to lower their health care costs.

As usual, I always welcome feedback and questions. Please be sure to click on “Like” if this was useful and enlightening, or “Leave a Comment” by clicking on “Comment” below.

Have a wonderful week and happy holidays to you all. I look forward to seeing you back here next year.

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