This past weekend, I made a presentation to a group of 20 or more spine surgeons on the topic of “Improving Your Surgical Outcomes With Better Patient Selection”.  This was at the New England Spine Study Group meeting in Springfield, MA.  That’s also the home of the Basketball Hall of Fame where our meeting was actually held, in their lovely auditorium.  After the meeting adjourned, I had the afternoon to tour the H. of F., which was great fun for this long-time basketball fan.

My 30-min. presentation focused on the rationale and benefit of utilizing a special form of clinical evaluation of low back and neck pain patients developed by Robin McKenzie and often referred to as “Mechanical Diagnosis and Therapy” (MDT).  My intent was to make the case for incorporating that assessment somewhere along the care pathway leading up to the surgeon’s decision.  Happily, rather than focusing on the potential loss of surgical cases, surgeons instead expressed their appropriate concerns about not wanting to perform unnecessary surgery.

You can learn more about those MDT methods in some of my other postings and in my books, found at www.selfcarefirst.com.

I told them about four published studies (see references below) that all document that this form of assessment can identify patients who would otherwise have undergone unnecessary surgery if not provided the opportunity to identify that their condition could still recover using non-surgical care.  Whether this form of evaluation is offered at the fairly late point of surgical decision-making, or much earlier in a patient’s care, it is extremely important for both recovery and cost outcomes.

You see, in each of those pre-surgical studies, as many as 52% of patients were able to rapidly diminish and eliminate their own pain, and thereby avoid surgery. One study reported that just over half of the individuals with full sciatica and neurologic deficits were able to eliminate all their pain themselves within 2-5 days after their MDT evaluation was finally performed just prior to being scheduled for surgery.  They eliminated their pain using only some simple “disc-correcting” exercises.

In an earlier blog posting, you can also read about a friend of mine who was scheduled for surgery when finally provided the opportunity to be evaluated with MDT principles.  His response during the initial evaluation was very encouraging and he consequently cancelled his scheduled surgery and was able to completely recover using some simple exercises and other self-care strategies.  He only wished his family physician, or anyone else for that matter, had referred him for that evaluation many months before when he would have recovered even more quickly but, most importantly, he would have avoided all those months of pain and disability, along with all that unnecessary cost to his health plan.

Such rapidly reversible cases are especially common in those whose back or neck pain is of recent onset, generally referred to as “acute”.  Studies report that 70-89% of acute back and neck pain patients have this rapidly reversible kind of condition that can only be identified by using this form of MDT evaluation.  Unfortunately, whenever this assessment is delayed, many of these individuals’ pain becomes chronic and that percentage whose pain is rapidly reversible drops to 45-55%.  Even though that’s still a sizable percentage of chronic pain that remains rapidly reversible, it also means that many back conditions lose their ability to rapidly reverse that they had when they were acute.  This sizable subgroup of patients has lost its window of opportunity to rapidly reverse the underlying painful condition before it deteriorated and became irreversible.  The solution to their problem, if there still is one, is often much more complex, sometimes even requiring surgery that could have been prevented.  For so many, an early assessment using MDT methods avoids so much pain, disability and cost.

One of the spine surgeons who heard my presentation caught the importance of educating family physicians about the value and importance of providing this assessment early for their back and neck pain patients.  He expressed interest in developing an educational effort for the family physicians in his community.

I believe there will be a point in the next few years when the standard of care for acute and subacute back and neck pain will become the provision of this special form of assessment.  The prevalence data speaks clearly that, if this assessment is not implemented in time, patients with either acute back or neck pain can lose that window of opportunity, finding themselves instead on a slippery slope, in danger of sliding into long-term (chronic) pain at considerable expense to themselves, to society, and to employers who are paying the tab.

Unfortunately, most family physicians remain unfamiliar with MDT and all its benefits to them and their patients.  All the scientific studies that validate MDT have been published in spine care-related journals that are unread my family physicians.  We need to establish educational opportunities to influence their education on this topic.  One way I’ve attempted to help is by writing two books entitled “Rapidly Reversible Low Back Pain” and “Solving the Mystery”.  Family physicians who have read them have found them extremely enlightening.

Some hospital and physician networks have expressed interest in educating their primary care docs in order to improve both the quality and the cost of spine care in their communities.  That is an excellent step and we need expand that to a much broader scale across the family medicine practicing and academic profession, as well as within the curriculum of their training programs.

Please leave comments and your input regarding ways to deliver this education so we can substantially halt the flow of acute to chronic back or neck pain.  You may visit www.selfcarefirst.com for more information.

1. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain: A predictor of symptomatic discs and anular competence. Spine. 1997;22(10):1115-22.

2. Kopp J, Alexander A, Turocy R, Levrini M, Lichtman D. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus, a preliminary report. Clinical Orthopedics. 1986;202:211-8.

3. Laslett M, Öberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. The Spine Journal. 2005;5:370-80.

4. Rasmussen C, Nielsen G, Hansen V, Jensen O, Schioettz-Christensen B. Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine. 2005;30:2469-73.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

Robin McKenzie developed the evaluation and treatment approach to managing back and neck pain known as “Mechanical Diagnosis & Therapy” (MDT).  I had the good fortune of meeting Mr. McKenzie in 1981 when I was first in private orthopedic practice.  A good friend and physical therapist dragged me to a four-day course McKenzie was teaching in Syracuse, NY.  I think I only attended one of the days but I saw some remarkable things there that planted a seed that slowly grew and changed my entire professional focus over the next thirty years. During the 80’s, I transitioned from my sports medicine, orthopedic surgical, small town practice to a research-oriented, non-surgical, large medical center spine practice.  But that’s a story for another day.

Today I want to focus on Robin McKenzie and what he has contributed that is of such great importance.  He is world-renowned in the field of spine care for his unparalleled contribution to evaluating and treating back and neck pain.  The methods he developed and investigated for more than two decades starting in the mid-1950’s in his own New Zealand clinic determined that a high percentage of back pain is caused by a condition that is usually rapidly and quite easily reversed or corrected.  He was decades ahead of anyone else in determining that most people could rapidly reverse their own problem using simple-yet-very-specific pain-eliminating exercises and posture modifications that could only be identified for each individual using his unique form of clinical examination.

McKenzie’s contribution has not so much been about how to treat back or neck pain, but how to evaluate it.  He developed some simple but very special clinical tests that became the focus of his routine office examination.  Specifically, his most important contribution was to have individuals bend their lumbar spines repeatedly to end-range, meaning as far as they can comfortably bend, testing one direction at a time, doing so both while standing (loaded) and then while lying down (unloaded). By monitoring how their pain responded during, and as a result of, this type of testing, very important features of the underlying condition were revealed.

Why is that so important?  Because most physicians, whether its your family practitioner or the spine expert in the Medical Center’s Spine Institute, only have their back and neck pain patients bend their spines once in each direction, to see how limited their movement is.  However, McKenzie has taught us how incredibly informative performing these bending tests repeatedly can be.

Here’s the difference.  If an individual with low back pain performs a standing back bend only once (see below), what most doctors routinely request, that single movement often causes the pain to briefly increase.  For many doctors, that increase promptly suggests that the pain may be coming from one or more facet joints.  Those are small joints located in pairs in the back of the spine that are loaded or compressed with backward bending.  Too often, doctors conclude from that increase in pain that back bending should be avoided, figuring that it may be aggravating the underlying problem.

A standing backbend is one of many valuable spinal bending tests, if performed repeatedly.  For many, it can also become a very helpful pain-eliminating treatment exercise.

However, if patients are then directed to perform this same backbend test repeatedly, each time bending as far back as they can, this very same movement, as it’s repeated, often becomes progressively less painful.  Many also have pain radiating into their buttock, thigh, or lower leg. These test movements often begin to eliminate the furthest-away pain first and, with even more repetitions, the rest of the pain subsides until only midline back pain remains.  Additionally, their ability to bend backward progressively increases.  If more repetitions completely eliminate the back pain, the ability to bend backward will be completely restored as well.

So the very direction of testing that increased the pain on just the first try ended up progressively eliminating the pain with more repetitions.  This testing teaches both the clinician and the patient how to quite easily eliminate the pain.  Of further importance, if the pain returns again, whether in the car, at home, or at work, the patient can promptly return to this same movement and eliminate their own pain again.  So what began as a test ended up being a very effective self-care tool for the patient.

So McKenzie’s greatest contribution was to discover that the results of a common spine-bending test movement, if performed only once, often leads clinicians to draw an incorrect conclusion: in this case that extension should be avoided.  But when that same test is performed repeatedly, just the opposite is true.

I cover this in greater depth, including why this happens, in both of my books that can be found at www.selfcarefirst.com.

Pain that can be eliminated so rapidly in this way, and then its return prevented the same way, means that the underlying painful condition was dynamic, easily changeable, and, most importantly, reversible. Specifically, it somehow benefits from a single direction of repeated end-range movements, very often by bending the lower back backward.

While most people with back or neck pain can learn how to eliminate their pain and then keep it from returning again, there is a small percentage whose pain does not respond in this way.  When tested in this same way, their pain is either unaffected or even temporarily irritated.  But that is also important information for those individuals who need to undergo other forms of evaluation and treatment.

So the big question for everyone suffering from back or neck pain, and for their doctors: is there a way to rapidly reverse this condition to bring about a rapid recovery?  An evaluation using the principles Robin McKenzie has brought to us can determine that.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

You’ve no doubt heard the version of “The Golden Rule” that says: he who has the gold makes the rules.

Well, there’s often a lot of truth to that.  But unfortunately, that version of “the rule” doesn’t apply to you employers regarding your ability to control your rising costs, nor the quality, of your employees’ health care…….just because you are paying for it!!! Your costs keep increasing with little, if any, evidence you are getting any better quality for your money.  You have the gold but you have very little control over the rules.

Well, times are changing, at least in one big area of healthcare.  There’s some light at the end of this tunnel……and some very good news for your bottom line.  While the care of back and neck pain and other musculoskeletal conditions (including painful shoulder and arm conditions, as well as hip, knee, ankle and foot problems) keeps skyrocketing, you not only can stop that increase, but employers are starting to substantially lower their costs for care of these conditions. Learning about and then implementing some enormously valuable innovations in the care of these spine and musculoskeletal conditions is what will enable you to gain considerable control over your local health care marketplace, that will in turn greatly improve both your employees’ welfare and your bottom line.

To begin to take control of all this expensive care, I’d recommend doing four simple things:

1 – ask those who currently care for your employees to show you their data as to their short- and long-term outcomes/recoveries for treating these specific conditions. Unfortunately, most don’t even have this data. You see, most are too busy discovering new ways to deliver more care for your employees, to generate more income for themselves, without great concern about its quality.

2 – inquire about the same data for those using Mechanical Diagnosis & Therapy (MDT) methods of care for these same conditions. Much of these data can be found in some of these blogs or in my two books, both found at www.selfcarefirst.com. Unfortunately, many of those clinicians aren’t tracking their outcomes either, BUT, many are.  For example, in just their care of back and neck pain alone, one network of high-quality MDT clinics saved one payer millions by providing such good long-term results that back and neck pain recurrences were reduced by more than 80%, which reduced the need for MRIs by more than 70% and spine surgeries by 45%, all with patient satisfaction of 97%.  And we all know that satisfying employees with their health care these days is not easy. To do that, coupled with the huge cost savings, is an unbeatable combination for the employer.

3 – Consider spending a little more upfront to reward and therefore motivate clinicians to deliver and monitor excellent short and long-term recoveries that will then help you save lots of money in unneeded, expensive, additional care. That means transitioning away from paying and rewarding providers for simply prescribing more treatments, so often useless, called volume-based reimbursement, and instead pay a bit more upfront to reward and motivate the delivery of high quality outcomes, or value-based reimbursement.

4 – conduct a small pilot study to determine the extent to which this value-based reimbursement model and the utilization of high-quality MDT clinicians can bring you substantial long-term savings.

Through SelfCare First, I would by happy to help you review and implement these steps with the intent of significantly lowering your costs of caring for these very common and currently very expensive musculoskeletal problems. It is now possible to escape being at the mercy of so many well-meaning, but often ineffective and expensive, clinicians in your community from whom your workers are seeking care.

To learn more about this, “Leave a Comment” to me below and visit www.selfcarefirst.com and follow the “Employers” pathway.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

We’ve all read about individuals who have had near-death experiences.  But what about a “near-surgery experience” (and rescue) for someone in excruciating back and leg pain?

Last week, I had dinner with a good friend and reminisced about his “near-disc surgery” experience three years ago and how grateful he was to have avoided his scheduled operation.  He had developed severe back and leg pain and numbness in his foot that all started as just back pain after carrying some heavy equipment, falling on the ice three weeks later, and then cutting firewood for two hours.

Because he also developed some thigh pain, he was initially misdiagnosed by his family doc as having a hamstring tear.  But his pain became severe, interfering with his recreational, work activities, and simply walking.  Over the next 4-5 months, he saw a massage therapist, a chiropractor, a Reiki therapist, had cranio-sacral therapy, and treatment by a physical therapist while also trying Advil, Prednisone, Hydrocodone, Vicodan, Percocet, Neurontin, muscle relaxants, and had two epidural injections. But his pain and ability to function just kept worsening.

An MRI eventually showed a bulging disc compressing a nerve in his lower back.  Because of his excruciating pain and lack of improvement with all these treatments, he felt he had no choice and reluctantly consented to be scheduled for disc surgery.  Only then was he finally examined by a physical therapist trained in Mechanical Diagnosis & Therapy (MDT).

That unique examination revealed that certain movements and positions began to take away his lower leg and foot symptoms, indicating that his disc pain was possibly reversible and correctable, without surgery. As directed, he continued these specific pain-relieving movements/exercises and some posture changes at home. When his leg pain continued to improve, he decided to at least postpone his surgery.  His continued improvement also enabled him to progressively discontinue his numerous medications.  His foot numbness soon disappeared and his ability to walk and bend his lower back in all directions also progressively improved.

I also had given him a copy of my newly published book “Rapidly Reversible Low Back Pain” that he still says was “powerful” in helping him recover and understand what he was going through and why no one had introduced him to this kind of care long ago.

Six weeks after starting his MDT care, he was able to return to work and was soon pain-free.  He continued his simple exercises to keep his pain from returning.  He was elated to have complete recovery from this extremely painful disc problem while also avoiding the pain, apprehension, risk, and uncertainty of undergoing surgery.

At dinner, now three years later, he told me he remains pain-free, doing everything, including being a very active recreational athlete.  He had one brief, mild episode of back pain two years ago that he quickly eliminated using the same methods that helped him recover from his bad episode.

He is very grateful that he was finally taught how to eliminate his own pain that enabled him to dodge that surgical bullet that was about to strike him. He knows that if he hadn’t run into MDT care, and read that book, that he would certainly have undergone surgery.  He also realizes that his surgery, even if it had have been successful, would have been unnecessary.

One more thing.  He knows how many different clinicians prescribed and provided ineffective and even misdirected care.  If he had just been referred for evaluation and treatment with someone well-trained in MDT principles at the outset of his care-seeking, he would have recovered much earlier, much faster, avoided all those useless and expensive treatments and drugs, and not had to miss work and all his family and recreational activities for all those months.

My friend’s experience is not unusual, both from the standpoint of being treated with useless remedies but finding that even the most severe back problem can often be reversed easily with some simple-but-precise exercises.  There are at least four published studies all showing that 50% of those who are considered by their doctors to be candidates for disc surgery can still recover, usually much more quickly than my friend, when MDT methods of evaluation and treatment were properly implemented.

In fact, just like my friend, many other studies show that most back and neck pain sufferers can rapidly recover using self-care exercises and posture changes, providing they are evaluated properly using MDT methods.  Maybe your back or neck pain will respond rapidly like this too.

To find out more about how you, your patients, or your employees might be able to recover early and quickly from both simple and severe back and neck pain, come to www.selfcarefirst.com

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: selfcarefirstblog.wordpress.com

In his book entitled “Innovator’s Prescription”, Clayton Christensen describes three eras of medicine: intuitive, empirical, and precision.

The intuitive era is characterized by highly trained, usually expensive, professionals who solve medical problems through intuitive experimentation.  They use and re-use treatments that just seem to work for them.

As medicine evolves, an empirical era emerges where data are amassed that show there are certain treatments that seem to work better when treating patients on average.  This era is often referred to as “evidence-based” using randomized clinical trials that determine what works best for the average patient suffering from a non-specific symptom.

In the precision era, each individual’s disease or disorder can be diagnosed with such precision that a predictably effective, standardized treatment can be identified that addresses the cause of that individual’s problem rather than just the symptom.

Christensen points out that the care of infections moved through all three of these eras. Once diagnosed intuitively as immorality or weakness of faith, and then empirically as a result of unsanitary conditions in a city, as technology progressed, microscopes and staining techniques enabled the identification of microorganisms, some harmless and some deadly.  Identifying the specific organism causing an infection provided clues about the aggressiveness and spread of the disease, a patient’s prognosis, and, over time, enabled the development of consistently effective therapies. Infections used to account for the majority of health care costs but that has declined to about 5% per year of what it was in 1940. They now comprise just a tiny part of the U.S. health care budget.

The treatment of non-specific low back is following this same path.  Care remains in the intuitive phase for those clinicians who choose their treatment based on their best theory as to what causes most low back pain, and then often prescribe their favorite treatment.  Thousands of randomized clinical trials over the past 25 years have defined our current evidence-based/empirical era that has, not surprisingly, failed to identify an effective treatment for the “average patient” with non-specific low back pain.  After all, are any care-seeking patients “average”?

When an anatomic diagnosis is confidently made of a herniated disc causing sciatica and a neural deficit, even that diagnosis lacks sufficient precision to guide predictably effective treatment or determine early whether or not recovery can occur without surgery.

Ironically and unfortunately, most academic spine clinicians, researchers, and policymakers are deeply committed to empirical care with little or no understanding or vision for the importance of moving toward precision medicine.  They incorrectly think that RCTs of a non-specific symptom will somehow identify a predictably effective treatment for most patients.

So how do we move toward a precision diagnosis for low back or neck pain?
When we take our car to a mechanic seeking help with a problem, he doesn’t start by taking pictures of the car or its engine.  He begins by asking details about how the car is misbehaving and then takes it for a test-drive to personally evaluate its behavior so he can determine what treatment it needs.

It is similarly valuable and informative to “test-drive” a painful low back or neck while monitoring for familiar patterns of symptom response.  Numerous studies show that this form of dynamic assessment, part of an approach to spine care known as Mechanical Diagnosis & Therapy, provides far more precise information about the pain source than does most physicians’ clinical examination and way more than is provided by spinal imaging. This assessment can also uniquely identify predictably effective treatment for the great majority with low back and neck pain.

Unfortunately, the extensive evidence that validates this MDT form of assessment continues to be ignored by most spine experts who remain deeply entrenched in the empirical phase of spine care.  Despite 25 years of minimal progress in identifying effective treatments for non-specific low back pain, most experts remain fixated on finding ways to improve studies that still focus on subjects with a non-specific symptom.

The MDT assessment research has strongly established that the underlying cause of most low back and neck pain can be corrected quite quickly and easily without having to make an anatomic diagnosis. Making a precise dynamic mechanical diagnosis is far more informative and cost-effective than making a mere anatomic diagnosis. I’ll write about this more in future blogs.

The MDT assessment and its extensive research support is ushering in a new decade of spine care focused on establishing a far more precise diagnosis.  This is good news for everyone, especially patients and employers.  Identifying a precise mechanical diagnosis early will not only bring about rapid and inexpensive recoveries, there will be much less need for expensive spinal imaging, prolonged non-surgical care, injections, medications, and surgery.

For more information on this and many other topics, go to www.selfcarefirst.com.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
http://www.selfcarefirst.com
See the new patient education book: “Solving The Mystery: The Key to Rapid Recoveries for Back and Neck Pain” at http://www.selfcarefirst.com

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