In contrast to all the turmoil about Obamacare and its roll-out, the most recent issue of Fortune magazine has an article by Becky Quick (p. 66) who reports on Mark Bertolini’s simple three-point prescription to “fix” the U.S. health care system. Bertolini happens to be the chairman, CEO, and president of Aetna, the insurance giant that insures 44 million American lives. He feels his three-point plan can “heal” U.S. health care.

His first step: eliminate fee-for-service and replace it with rewards for good outcomes. He points to the Institute of Medicine’s 2009 estimate that 30% of all spending on health care is squandered on inefficiency, fraud, and unnecessary services. He asserts that such wasteful spending could mostly be avoided. Applied across the $2.7 trillion spent on U.S. health care in 2012, that 30% reimbursement change alone would save $810 billion.

He describes today’s reimbursement system as “If I build it, I will get paid for it,” rather than “I get rewarded for making this person better.” Good outcomes should be the goal of both care and reimbursement, rather than simply reimbursing for the mere provision of services.

Second, Sutton’s Law: “Go where the money is.” We need to focus on the big ticket items, the heavy users.  Improve the quality of care for the expensive disorders.  Aetna’s current focus is on diabetes, estimated to cost $130 billion a year in the U.S.  He outlines Aetna’s program to slow the cost of diabetic management.

Third, re-structure the delivery system.  Send the hearts to the Cleveland Clinics and cancers to the Memorial Sloan Ketterings. This operationalizes rewarding those who get patients better rather than simply for developing new facilities and programs that don’t necessarily produce predictably good results.

Bertolini feels that this three-point plan “attacks the entrenched establishment that profits from the existing inefficiencies.” All three points are obviously intertwined.

Meanwhile, one of the biggest ticket items in health care is the cost of care for spinal and musculoskeletal conditions – an estimated U.S. annual cost of $800 billion, including disability costs.  The inefficiencies and unjustified variation in the management of these conditions are documented and substantial.  In my next blog, I will make a strong case for applying Bertolini’s three-point prescription to the management of most musculoskeletal disorders and cite some emerging claims data that not only stop the rapidly rising costs of this care but actually document a 40% savings!

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 weekend everyone.

RD & Dr.Sood

Dr. Ron and Dr. Sarveshwar Sood of India

In my last blog posting, I was heading to Dubai to give a presentation at the World Congress on Low Back and Pelvic Pain.  This conference is considered by many to be “the place” to hear the latest and greatest research from the world’s top spine and pelvic researchers. Attendees include clinicians (doctors, physical therapists, and chiropractors mostly) and researchers – both clinical and basic science. The Congress is held every three years in a different, and always attractive, city.  More than 1,000 attended this four-day conference from 58 countries. The conference venue was outstanding and Dubai a fascinating city.

I’m sure most considered the presentations to be excellent research, yet so many were in fact only lectures about myofascial and musculature anatomy and physiology of the spine and pelvis, but no clinical data. The rationale for these presentations?… these structures are essential to spine movement and stability, ergo, they must in some way be deficient in painful individuals and therefore in need of strengthening or stretching.  So many presenters offered no explanation for how pain is generated related to these structures and their deficiencies, nor did they present any data as to the beneficial impact when people perform exercises that theoretically address these alleged deficiencies. In other words, so what?  Interesting anatomy and physiology, but where’s the clinical relevance?

One positive and significant program feature for me was the final half-day that focused on the topic of subgrouping: why is it important, how to validate subgroups, and examples of subgrouping efforts.

The final talk of that final day by Hanne Albert, PT, PhD from Denmark, was especially well-received.  She is an excellent presenter who reviewed her research in identifying and validating a new, but very small, subgroup within the chronic low back pain population whose pain appears to be due to an infection within a disc that was previously herniated and now has Modic 1 changes in the adjacent vertebrae.  Her RCT reports that this small subgroup does quite well with antibiotic treatment vs. being treated with a placebo medication.

What is remarkable is that identifying and preliminarily validating this subgroup is being hailed as a major breakthrough by the spine care world, despite only one RCT.  Further, even if this is all true, it is still only about 1% of the LBP population.

Meanwhile, my presentation, described in some detail in my last posting, preceded Dr. Albert’s.  It focused on two cases of radiculopathy and how both became completely pain-free in just 30 min. and were able to avoid scheduled surgery.  They both then fully recovered within days, and remained pain-free when last checked two years later.  All this happened because of their mechanical (MDT) assessment followed by performing some simple, safe exercises without risk or side-effects.

But then I additionally presented a great deal of published evidence that these rapid recoveries are actually very common, occurring in 70-89% of acutes, 50% of chronics and radiculopathies, most axial neck and low back pain, as well as a good percentage of stenotics and spondys.

Of course, most researchers have never, or have rarely, seen a patient evaluated or treated, so they have no appreciation for the rapid and rather dramatic rate and ease of eliminating these patients’ severe pain, sensory loss, and tension signs, while simultaneously restoring normal movement and reducing the size of their disc herniations – all within their 30-minute first session!

Just one question was addressed to me during the subsequent discussion. I was asked how the status of a painful disc’s hydrostatic mechanism influences whether the pain can be centralized or not. I responded with the results of our study published in 1997 that compared the findings of the MDT evaluation in patients who promptly underwent discography that identified the status of the anulus and hydrostatic mechanism in centralizers, peripheralizers and those who had no change in pain with their MDT assessment.

Not surprisingly, conference participants without any MDT training were described by one as “spellbound” because, on one hand, these two patients’ presentations were very familiar to them, yet they had no idea that such severe disc pathology could be turned around so quickly and easily.  One U.S. physiatrist also noted that I was the only speaker to present so much data in my literature overview.

Nevertheless, my sense was that Dr. Albert’s presentation caused the greater buzz, by far.  So why was that?

On one hand, even if we assume that her Modic infection subgroup is validated, that still only represents a very small portion of non-specific chronic LBP patients.  Furthermore, treatment consists of 100 days of oral antibiotics that routinely creates GI side-effects, an occasional temporary blackening of teeth, and some treatment failures of course.  Pain relief doesn’t begin until weeks into the treatment and then often does not resolve completely.  Nevertheless, even this small validated subgroup is worthwhile identifying for those with this infection who otherwise would continue in pain.

On the other hand, the “reducible derangements” (dir. pref. and centralization) that I described account for 70-89% of acutes, 50% of chronics and sciaticas.  The treatment is simple, safe, routinely brings complete pain relief, usually in minutes, hours or a few days, and commonly leads to long-term freedom from pain for patients who perform very simple exercises on a regular basis and guard their posture a bit.

So how much ‘buzz” did my presentation create?  Only a handful came up to me at the gala dinner that night to comment.  So my sense is that it did not cause as much stir as Dr. Albert’s work. Was that because those dramatic recoveries I showed were viewed by some as too-good-to-be-true? Or perhaps these highly prevalent rapid recoveries were just too disruptive to clinicians’ rigid perception of back pain’s pattern of slow recovery.

Regardless, the evidence indicates that every patient with neck or low back pain should undergo an MDT assessment and every clinician should be obliged to provide such an assessment for their painful spine patients. The strong possibility of such rapid, simple, and safe recoveries should be made available to all.

As always, I 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 everyone.

I am traveling to Dubai this weekend to give a presentation at the World Congress on Low Back and Pelvic Pain. I’m speaking about how rapidly sciatica and cervical radiculopathy can often be corrected, enabling patients to recover both quickly and long-term.

I will present two cases, one cervical and one lumbar, each with a 4-6 week history of pain radiating all the way to the hand or foot and with some numbness in the hand or foot as well. Both patients were out-of-work due to their pain and referred for MRIs in consideration of surgery because they were not improving. One was actually scheduled for disc surgery.

On examination, they both had significantly positive “tension signs” in that extremity and considerable loss of range-of-motion (ROM) due to their pain, all captured nicely with photographs. They both had some loss of sensation as well and very large disc herniations on their MRI compatible with their clinical presentations.

Patients like this are very common and seek care from a wide variety of clinicians. Both patients had been referred to physical therapists but were unable to provide any help.

Surgery for disc herniations is commonly performed in cases like these and quite successful much of the time. But surgery is still a big deal since it always carries risk, simply by being in a hospital or operating suite. Though unlikely, risks are not small: infection (now-days includes antibiotic-resistant microbes), blood loss, drug or blood reaction, deep vein thrombosis, anesthesia complication or surgical error. Other medical errors are not uncommon inside hospitals. These things happen someplace, every day, when surgery is performed.

Then there’s also the possibility that the surgery won’t work, or won’t provide enough improvement to enable the patient to get “back to normal”. All these risks and complications, coupled with the pain and recovery time even if the procedure goes well, makes surgery the last resort, an opinion held by most every surgeon and patient.

But what happened to these two patients is noteworthy, but not because they are particularly unusual. Indeed, their good fortune could occur for at least half of the thousands, perhaps 10s of thousands, around the world who every day are in their predicament. They were shown a way to recover rapidly and fully, without surgery. How this was done has been described in textbooks, scientific studies, and taught to clinicians literally around the world. If you’ve never heard of this, and especially if you’ve also had sciatica or a neck radiculopathy, it’s simply because most physicians either ignore, are unaware of, this exceptionally attractive type of care.

Their good fortune occurred because the radiologist to whom they were referred for their MRI arranged to also undergo a special form of clinical evaluation that identified that their disc problem could be rapidly and easily corrected. For these two patients, that exam revealed that there was a simple way that each patient could move their own cervical or lumbar spine that promptly began to correct their herniation so they began to feel pain relief. First their hand or foot and then arm or leg pain went away, because of these movements, all in just a few minutes. Those same movements then eliminated the pain from their neck or low back. In just 20 minutes, they were both pain-free and able to bend and move about with no pain.

Their pain remained eliminated. They no longer had positive tension signs (straight-leg-raising was now negative) and their spinal movement was fully restored with no discomfort………..again, all in 20 minutes.

A repeat MRI right then showed a noticeable reduction in the size of their respective herniations.  I’ll be showing those MRIs in Dubai.

They were instructed to continue performing these pain-relieving movements several times each day and temporarily avoid any forward bending or slouched sitting. They remained pain-free and were gradually able to return to all forward bending activities over the next week. They were both fully recovered and back-to-work within two weeks and they had remained pain-free and fully active when last checked two years later.

Both rapid recoveries required only 3 visits with this specially-trained physical therapist because, after that initial evaluation and rapid change, the therapist merely served as a coach teaching them how to treat themselves throughout each day. The frequency of this very specific self-care is what prolonged their rapid improvement so they could so quickly return to all their daily activities.

The first major point: these rapid recoveries could have happened weeks earlier if their doctors had simply had them see a therapist with this type of training. So much of these patients’ suffering and work-loss was unnecessary, not to mention the wasted money spent on useless treatments.

The second major point: if these patients had not undergone this form of care, at least one, and likely both, would have undergone an unnecessary operation, with all its risks and expense. There are now four studies that show that this form of evaluation and care, when provided to patients considered to be disc surgery candidates, can bring about these rapid recoveries in 50%, thus avoiding what would have been unnecessary disc surgery.

Dr. John Wennberg, PhD, of Dartmouth Medical School, has said: “If operating on the wrong leg is considered a “medical error”, what do we call operating on someone who doesn’t need surgery?”

This form of mechanical care is called “Mechanical Diagnosis & Therapy”, also commonly referred to as “McKenzie Therapy”. Both the evaluation and treatment processes have been studied extensively and the success of these methods in rapidly correcting cervical and low back pain and their syndromes is very well-documented.

Yet every day in the U.S., thousands of patients are undergoing disc surgery without ever being evaluated in this manner to see if their pain can be mechanically corrected without surgery.

Patients deserve to know about this. Payers likewise deserve to know about this. Clinicians should be obliged to be sure patients are given this opportunity to recover easily and quickly, not just before surgery is considered, but early in their pain episode so surgery never has to be even contemplated.

Not every patient will respond this way. But the published studies report that 80-90% of acute low back and neck pain will resolve this quickly and easily. By the time patients’ pain becomes more chronic, or to the point of considering surgery, their chances of a rapid recovery like I’ve described here is reduced to about 50%.

How would you like to be treated? When the evidence of the effectiveness of this type of care is so strong, for spine care doctors, therapists, and chiropractors to not provide this type of care is simply unacceptable.

I’ll address this more in my next posting. 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 everyone.

I wrote in my last posting that published data document that the current U.S. system of spine care appears to be actually accelerating the development of chronic pain, work disability, narcotic addiction, use of injections and surgery, and guideline-discordant care in general. Sky-rocketing costs tied to increased utilization of unproven invasive procedures and devices have produced little, if any, evidence of any improvement in patient outcomes. The growing use of MRIs generates misdiagnoses while more opioid prescriptions lead to more addiction.

This decline in quality and rise in cost is directly related to ineffective guidelines that stem from 100’s of RCTs of variable quality that all focus on the study population with non-specific (NS) LBP. The very best these RCTs and guidelines can produce is to determine the best treatment for the average patient with this non-specific symptom. Is it any wonder that guidelines conclude that the best treatment is completely non-specific, one-size-fits-all, specifically encouraging everyone to return to activity ASAP and to reassure that this self-care strategy is likely to result in recovery at some point?

Einstein defined insanity as doing the same thing over and over again and expecting different results. If we change nothing and persist in studying NS-LBP rather than making some diagnostic progress, we will learn nothing new.  We will spend another 25 years learning how to best treat the average patient with this NS symptom.

Two published surveys of international LBP researchers, published in 1998 and 2012, both reported the identification and validation of LBP subgroups as the #1 research priority. There is an urgent need to find ways of identifying or characterizing individuals’ actual underlying disorder and treating that, rather than just a NS symptom. That requires identifying diagnostic subgroups.

Kevin Spratt, Ph.D., an eminent spine researcher at Dartmouth Medical Center in New Hampshire, wrote in 2003 about a research strategy intended to identify and validate subgroups. He referred to his paradigm as the “A-D-T-O” research model. A-D-T-O stands for Assessment – Diagnosis – Treatment – Outcome. Just as A-D-T-O represents the conventional order of clinical care of individual patients, Spratt wrote that it should also be the order for investigating and identifying the best treatments for clinical subgroups.

He points out that these four A-D-T-O pillars are connected by three research links. Establishing the A-D link is where the research effort must begin.  This fundamental link requires conducting inter-examiner reliability studies focused on the assessment process-of-interest in an effort to distinguish between those who are members of a diagnostic subgroup and those that aren’t.  Any further research targeting a subgroup cannot be justified if its members and non-members cannot first be reliably identified.

Only after this A-D link is established can the D-T link utilize observational cohort studies focused on members of this subgroup to determine if improved outcomes can be produced with a single treatment. Can data be generated that indicates that this subgroup has a favorable prognosis if treated in a specific way or ways?

Once the A-D and D-T links have been established, the third and final link seeks to determine the best treatment for this reliably identified subgroup. Only now are randomized clinical trials (RCTs) justified to compare treatments previously identified as promising as a result of the prior D-T studies. Substantially improved outcomes with any treatment are required, i.e. the only way, to validate that subgroup.

Any subgroup validated by outcomes can now be subtracted from that very large NS-LBP subgroup.  In the case of one very large subgroup that has substantial evidence in all three of the A-D-T-O links, this large NS-LBP black box is now significantly diminished.  That subgroup is the one whose members’ pain can be centralized/abolished with a directional preference. This subgroup carries a ‘patho-mechanical’ diagnosis of ‘reducible derangement’ where a patho-anatomic diagnosis is not always possible. I’ve talked about that subgroup a great deal in prior blog posts and will be doing so soon again.  Most spine stakeholders are unaware of this evidence, this subgroup, and this A-D-T-O research paradigm.

This A-D-T-O research model is simple, straight-forward, and focuses on moving spine care toward patient-specific treatments. Because it is either unfamiliar to most LBP clinical researchers, or is viewed as too disruptive from the current research convention of conducting high-quality RCTs that target the best treatment for NS-LBP, it is not in wide use yet. Studies that do comply with this new research paradigm have consequently been ignored by clinical guideline panels that are fixated on the high value of RCTs with little regard for the limitations of continuing to focus on NS-LBP.

The A-D-T-O model should be the basis for future clinical research for any disorder, particularly one characterized by a non-specific symptom. Health care clearly needs to shift its attention toward individualized care and that requires a shift in the overall research paradigm.  We should not waste more time and money conducting RCTs of NS-LBP that, over the past several decades, have produced only one-size-fits-all non-specific care that is not improving either the quality or cost of spine care.

I 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 everyone.

I am continually reminded of the ineffectiveness of most clinical spine research and virtually all guidelines that collectively block any improvement in either the quality or cost of spine care.  The latest documentation is this month’s lead article in the BackLetter (“U.S. Spine Care System in a State of Continuing Decline”, Vol. 28, No. 10, October 2013).  Its focus is on the “state of crisis” in spine care within the U.S.

A new study is cited (Mafi et al: Worsening trends in the management and treatment of back pain/JAMA Intern Med/2013) that presents data that this system is actually accelerating the development of chronic pain, work disability, narcotic addiction, use of injections and surgery, and guideline-discordant care in general.  Sky-rocketing costs tied to increased utilization of unproven invasive procedures and devices have generated little if any evidence of any improvement in patient outcomes. The growing use of MRIs generates more and more mis-diagnoses and more opioid prescriptions lead to more addiction. That’s our predicament after more than 1,000 randomized clinical trials and hundreds of millions spent on research and guideline creation over the past 25 years.

What is particularly disturbing about this article is the analysis by experts as to why we are in this situation, and their ideas about solutions. They understandably, but mistakenly, put all their confidence in the recommendations of clinical guidelines.  Their explanation for this crisis is primarily clinicians’ non-compliance with guidelines and recommend that doctors provide far less treatment for both acute and chronic low back pain (LBP) and let the favorable natural history (NH) run its course to recovery for most.  That would make some sense, IF the natural history was truly as favorable as they believe.  I repeat…..if.

Many studies challenge that view of NH (i.e. Donelson et al: Is it time to rethink the typical course of low back pain? PM&R Journal. 2012;p394–401). There are very credible population-based studies that continue to be ignored by those who we would expect to be very familiar with the breadth of this literature. But those same experts seem irreversibly entrenched in the belief that a high percentage of LBP recovers on its own within 90 days.  The data supporting that belief are simply flawed and those population studies, though highly credible, remain unacknowledged.

Meanwhile, this article correctly points out that the exam room reality is that it takes far less time, with the same reimbursement, to order an MRI, write a narcotic prescription, or refer to a specialist than to explain to a patient in pain the optimism supposedly tied to NH and the rationale for not prescribing those interventions. So guideline-concordant care is just not going to happen, unless guidelines change (see below). Further, the lack of validity for any treatment gives clinicians license to prescribe whatever treatment he or she wishes. After all, if the NH is that favorable, even an ineffective, unproven treatment can appear successful to both the clinician and the patient if the patient recovers by NH.  The classic line: don’t believe your treatment was effective just because the patient got better.  Of course, the generous reimbursement for those treatments further incentivizes guideline-discordant care.

But there is an even more fundamental blind spot in these experts’ point-of-view. Throughout this entire BackLetter article, the symptom of “low back pain” is treated as “the diagnosis”. The article’s focus, just like the vast majority of RCTs and literally all guidelines, is entirely on how to treat this non-specific (NS) symptom.  That modus operandi drives the near-universal acceptance of the notion of one-size-fits-all care, or treating every patient with LBP the same, with NS-treatments like advice to keep active and reassurance of likely recovery in time.  Is it not surprising that hundreds of studies of a NS symptom would only yield NS solutions for the average patient? And is everyone truly the same?  Do none of these experts get it that a bell-shape curve and a bimodal curve focused at the two extremes of the population can have the same mean?

Such recommendations also ignore patients’ understandable sense that there is something terribly wrong and terribly painful somewhere in their back.  “Let’s find out what it is” (get an MRI), and ‘I need pain relief!!”  Again, the doctor gets paid the same for the 5 minutes to write a prescription or make a referral as for the 15 minutes required for patient education. And of course compensation is much greater if a treatment is actually provided, especially if it is invasive.  This perverse reimbursement incentive is substantial.  And all this significantly distracts from the fundamental, even essential, need to figure out how to more precisely diagnose and in turn treat these patients.

Incredibly, there is no mention in this article or, in fact, in any guideline, of the importance and value in discovering something more about the underlying pain generator.  In contrast, two different surveys of international LBP researchers spanning the past 15 years both concluded that the #1 research priority is the identification of valid LBP subgroups (Borkan et al/Spine/1998 and Pransky et al/Spine/2011).  Where is that priority in this article?  After all, isn’t that the only way we will ever move spine care toward more individualized, patient-centric, and cost-effective care?

Paul Batalden at Dartmouth has often stated: “Every process is perfectly designed to get the results it gets.” So what is the process that has been so perfectly generating what is acknowledged in this article as this declining spine care system?

As I see it, the research cards are solidly stacked against making progress in improving care.  For example, the highly regarded Levels of Evidence (LOE) hierarchy that has become the basis for spine-related clinical research and evidence-based care ironically de-emphasizes the importance of the most important focus of LBP science: diagnostic subgroup research. The basis for that de-emphasis appears to be the belief that we simply can’t make a good diagnosis in most cases and may never be able to. If our current advanced imaging can’t do it, it’s unlikely we’ll ever be able to identify anything that will uncover the true source of pain.  Of course, theoretical explanations for LBP abound and are offered to most every patient to justify the clinician’s favorite treatment recommendation.

But the LOE construct includes an absurd approach to diagnosis research based on requiring a  “gold standard” in order to produce a credible diagnostic advance.  How can one possibly have a gold standard when 85% have no means of diagnosis?  Those who accept that research construct obviously never expect to see any headway in making a diagnosis in those 85%.

For decades, the evidence-based process in researching spine care has focused on, and been quite content with, seeking the best treatment for the average patient with this NS symptom. But we don’t have guidelines for abdominal pain, elbow pain, or knee pain, obviously because there are subgroups in each of those body regions for which there are subgroup-specific treatments validated with outcomes evidence.  But with LBP, we have entire guidelines focused on a regional symptom!

Guidelines and RCTs make a feeble attempt at subgrouping by focusing on acute vs. chronic LBP with the belief that they are two different clinical entities.  But there is now evidence that many members of those two duration-based subgroups have far more in common than they have differences (Donelson et al: Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. PM&R Journal. 2012;p667-81).

The Quebec Task Force was the first comprehensive LBP literature review back in 1987.  It tried to shed light directly on this blind spot when it wrote that “the diagnosis is the fundamental source of error….. Faced with uncertainty, physicians become inventive.” But it changed nothing. According to this article, no acknowledged progress has been made.  Our inability to make a precise diagnosis not only remains the fundamental need, it’s importance is our greatest oversight that lies at the heart of our decline in spine care.

There are two other critical parts of the spine care diagnostic blind spot. First is the belief that a LBP diagnosis must be an anatomic one. The second is an entire body of literature ignored by guidelines as well as many researchers and experts that focuses on identifying and validating LBP subgroups based on clusters of clinical findings. I’ve written extensively about that here in prior blog postings and in my first book: Rapidly Reversible Low Back Pain.

Despite the policymakers’ and pundits’ concern about the decline of spine care, and despite over 1,000 RCTs, there are numerous reliability and prospective cohort studies, RCTs, and systematic reviews that strongly validate certain diagnostic subgroups.  But these studies, just like the population-based NH studies, are ignored, even though they: 1-define clinically-relevant characteristics of the large majority of acute and chronic LBP as well as those with axial pain or sciatica; and 2-identify predictably effective subgroup-specific treatments. These studies strongly suggest that acute NS-LBP can be reduced from 85% to 20% or less of the LBP population.  Those two factors alone represent a major advance in spine care that, if widely implemented, would quickly reverse the decline in spine care depicted in this article.

So why does this extremely important blind spot even exist? Why the inability or reluctance to even acknowledge these studies or see any connection between the need for a diagnosis and the perceived current spine care crisis? That discussion is for a different time and place.  But how can we possibly improve care in this huge and expensive population that struggles with this NS regional symptom without addressing and researching the topic of diagnostic subgrouping as a top priority?

What is so frustrating is that theses ignored studies provide answers!!!…..important ones.  In future blogs, I’ll write about those research strategies and discuss just how precise a diagnosis must be in order to identify predictably effective patient-specific care.  And it needn’t be an anatomic diagnosis!

I’ve run way too long, but there is much more to discuss.  I’d love to hear from you.  Please be sure to click on “Like” if this was useful to you, or “Leave a Comment” (click on “Comment” below).  Have a great week everyone.

Recently, Jeffrey Immelt, Chairman and CEO of General Electric and also Chairman of President Obama’s Council on Jobs and Competitiveness, spoke about health care reform at Dartmouth College in New Hampshire: “We’re investing in really neat, high-end technology, but we’re also investing in low-end, low-cost, and low-price technology.”

We don’t often find “technology” and “low-cost” in the same sentence. Read the rest of this entry »

The cartoon showed a doctor in his office talking with his patient, saying: “I’ve just consulted with my accountant and he says you need surgery.” Like most jokes, the humor here is tied to an element of truth. Surgeons are often recognized for their financial conflict-of-interest (shall we say “economic bias”?) as they decide whether or not to recommend surgery.

Read the rest of this entry »

Dr. John Wennberg, Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice, has asked: “If operating on the wrong leg is considered a medical error, what do we call operating on someone who doesn’t need surgery?” Operating on the wrong leg is every surgeon’s (and patient’s) worst nightmare, but Wennberg infers that operating unnecessarily is of even greater concern. Read the rest of this entry »

While the term “McKenzie care” is very familiar to most physicians, it is a greatly misunderstood form of care. Because family physicians and internists play such an important role in initiating care for back and neck pain, it’s important for them in particular to understand just what McKenzie care is. So let me briefly cover ten things that all health care practitioners, but family docs in particular, should know about McKenzie spine care. Read the rest of this entry »

First, I’d like to wish everyone a very Merry Christmas and may 2012 be a year of prosperity: physically, spiritually, emotionally, and financially.

I have advocated the benefits of making a mechanical diagnosis in individuals with back and neck pain since I first learned about how this was done 30 years ago. It was so impressive to see Robin McKenzie use his spinal movement testing methods to identify what proved to me over subsequent years to be very common patterns of pain response. These patterns enabled the classification of most patients into mechanical subgroups for which there were distinct and predictably effective solutions. Read the rest of this entry »

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