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.


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 »

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 »

Musculoskeletal (MS) conditions account for the majority of lost work and bed days due to health conditions. According to a report by the Bone & Joint Decade commission, they are the leading cause of disability and health care cost, as well as the most common health condition in the U.S.  The total U.S. cost of MS treatment and lost-wages in 2004 was estimated to be $849 Billion, or 7.7% of GDP.

In this large and very expensive MS arena, numerous studies show that many disorders can be resolved quite easily and quickly using some simple-yet-precise movements and positions of the painful joints that somehow actually correct the underlying problem and eliminate the pain.  The really good news is that, if you’re the one in pain, you can usually perform these movements and positions yourself.  But this requires your provider to first determine which movements, if any, will correct the problem and then teach you what to do.  This specific form of self-care, known as Mechanical Diagnosis & Therapy (MDT), empowers you to take control of, and eliminate, your own painful problem.

Unfortunately, these painful conditions are rarely treated in this way. Only a small percentage of individuals with MS conditions are provided the opportunity to be evaluated by a clinician with MDT training. Consequently, the painful conditions too often persist, even worsen, despite undergoing other extensive, expensive, sometimes even risky treatments. But most importantly, these treatments are all unnecessary for those who can recover using self-care first and MDT principles.

I wanted to advocate for this first type of MDT self-care across the spine care community in order to help individuals avoid these other ineffective and expensive treatments. I therefore founded Self-Care First in 2002. This blog is part of that effort. So whether your condition can be eliminated easily with MDT care or not, the best way to find out is to be evaluated by a practitioner trained in MDT.  In other words, first explore the potential and value of self-care.  Therefore…..self-care first.

Exploring self-care first is especially important in the many disorders that do recover, only to recur days, weeks, or months later. Low back and neck pain are common examples of conditions that frequently recur. Many treatments for these conditions are described as “passive”. That means your practitioner performs the treatment on your behalf, doing something TO you.  They may apply ice, heat, ultrasound, or diathermy to your painful area, or use their hands to massage, mobilize or manipulate your spine and other joints. But they are performing the treatment for you.  You are passive.

Even if effective in decreasing your pain, the pain usually returns again soon.  When it does, your experience tells you to return to get that same relief again for that same passive treatment from your practitioner.  So you seek that type of care again, and again, and again, that cycle repeating itself sometimes many times.  But you meanwhile learn nothing about how to treat yourself or how to prevent your own pain from returning.  You instead develop a dependence on your provider and this passive care while gaining no insight into why it keeps returning nor how to prevent it.  Some practitioners will deepen your dependency on them by recommending you return for treatment even after your pain has gone away in order to prevent your painful condition from returning.  But no data has ever shown that such treatment lowers the chance of having another episode.

Alternatively, if you had learned methods of self-care first that enabled you to eliminate your own pain, you would have also learned how to prevent your pain from returning, a necessary part of your recovery from your current episode as well as for preventing it over the weeks and months ahead.  And if or when your pain does return, you already know how to get rid of it by yourself, because what worked before usually works just as well now.  You have been empowered to be independent of your practitioner using the know-how learned earlier to quickly and effectively treat yourself.

There’s one other point that illustrates the importance of pursuing self-care first (MDT care).   In other blog postings, I described studies documenting that as many as 50% of individuals with back pain that had been considered disc surgery candidates, when finally provided this MDT evaluation, found out they had a rapidly and easily reversible problem all this time that would quickly resolve using self-care.  This enabled these individuals to avoid what would have been unnecessary surgery.

The overwhelming message for patients, clinicians, employers and health plans is to pursue MDT and self-care first.  To locate a practitioner near you that is trained to provide you with this form of care, click here.

Here are some books you may wish to read about MDT and self-care for low back, neck, and shoulder pain:

Treat Your Own Back, by Robin McKenzie

Treat Your Own Neck, by Robin McKenzie

Treat Your Own Shoulder, by  Robin McKenzie

Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain, by Ronald Donelson

Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings, by Ronald Donelson

Dr. Ron

Ronald Donelson, MD, MS

SelfCare First, LLC
Blog: blog.selfcarefirst.com

In my book “Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain”, I included the stories of two individuals, one with disabling neck pain and the other disabling back pain, both persisting for more than two years despite actively seeking care.

I was present when Peter was first examined for his chronic neck and arm pain.  It was a demonstration to attendees at an international spine conference of how the MDT evaluation identifies rapidly reversible conditions and then guides rapid recoveries.  References to “Figures” below pertain to illustrations in the book.

Peter is a 38 year-old adventure guide and instructor who was on his honeymoon when the car he was driving was hit from behind while stopped. He passed out at the scene and was taken by ambulance to the hospital where no severe injuries were identified. He was discharged, given Tylenol, and told to see his doctor when he returned home.

Severe headaches soon started that kept him from sleeping at night as well as pain and numbness progressing down his left arm to his hand. His physician at home sent him to physical therapy that he continued for 18 months.

His pain forced him to stop working because he couldn’t rotate his head when kayaking nor look upward when leading rock-climbing groups.

A neck MRI showed bulging/prolapsed discs at his C5-6 and C6-7 levels that were pressing against his nerve causing the pain and tingling in his left arm.

He was referred to a neurosurgeon who offered him surgery to relieve the pressure on the nerve.  He was told there was a 50% chance of improvement, 40% chance of being the same, and a 10% chance of worsening as a result of the surgery. Because he didn’t like those odds, he decided against surgery.

He was finally given the opportunity to be examined by a physical therapist with extensive training in Mechanical Diagnosis & Therapy (MDT). At that time, he reported he had improved only 10% over his 18 months of physical therapy. He had pain, numbness and tingling into his left palm and fingers as well as tension and tightness in his neck and aching in his left arm. He did report some improvement in those symptoms four months earlier when he changed his job and stopped climbing and kayaking.

Attempts to bend his neck in any direction seemed to increase his neck and arm pain, including bending his head and neck backward. But a special variation of neck extension (bending the neck backward) noticeably decreased the arm and hand tingling that then didn’t return, which he stated was a “huge difference” from his last 18 months. With more neck extension movements, his hand and arm symptoms improved substantially and remained better, which greatly impressed Peter.

The therapist told Peter that something was pressing on the nerve and they were perhaps learning that that “something” might be able to be withdrawn from the nerve so his pain and tingling would go away.

He was instructed to perform 10-12 repetitions of the cervical extension exercises 5-6 times/day.  He was shown how to perform them standing, sitting and lying down. He was shown how his forward head position when sitting aggravated his condition and was given a lumbar roll to use behind his lower back, especially in the car, to enable him to sit more erectly with his head positioned much better to keep from aggravating his condition while sitting (Fig. 22.6).

Using this self-care strategy, the tingling in his arm and hand disappeared almost immediately despite having been present for 18 months.  His headache, neck and arm pain progressively decreased over the next four weeks to where he no longer had any pain. He reported three months later that he was pain-free as long as he did his exercises. He admitted to only doing them 1-2 times per day and if he stopped those exercises for more than two days, his headaches would return very slightly which reminded him to return to his exercises.

He was able to return to all of his work and had even taken up snowboarding as a new sport that he could now include in his work.

In hindsight, Peter had an undiscovered rapidly reversible problem all this time. Like so many with motor vehicle whiplash injuries, his neck and arm pain didn’t begin until many days after his accident. He then underwent 18 months of useless physical therapy and almost accepted an unnecessary surgical procedure because neither he nor his physicians knew his underlying problem was actually rapidly reversible all this time. Fortunately, Peter finally found someone trained to evaluate and treat him using MDT principles of care.

Peter Is Not An Unusual Patient! There are published data indicating that half of chronic back and neck pain patients respond similarly. While not unusual, sudden and rapid recoveries like this are not widely known, which is why I have written my books and created this blog.  Unfortunately, and most importantly, such dramatic recoveries are also unfamiliar to most health care providers, payers and policy makers who do not provide their back and neck patients with this Mechanical Diagnosis & Therapy (MDT) form of evaluation.

From a cost perspective, every one of these patients who have an undiagnosed rapidly reversible condition costs tens, if not hundreds, of thousands of dollars in direct medical costs and lost productivity,……..all unnecessarily! It only requires a thorough MDT evaluation at the outset of their care to identify them early and guide their rapid recovery to avoid nearly all of that unnecessary expense.

Peter’s actual initial MDT evaluation at this conference can be viewed on DVD available at http://www.optp.com/A-Day-with-McKenzie-DVD_914DVD.aspx. The therapist on the DVD who assessed Peter is Robin McKenzie himself, who developed the MDT method of care.

Dr. Ron

Ronald Donelson, MD, MS

SelfCare First, LLC
Blog: blog.selfcarefirst.com


During these critical times of economic challenge and intense debate over health care reform, finding ways to reduce the cost of health care is central to solving our financial dilemma.  Many feel that both the quality and cost of health care are greatly influenced by how providers are reimbursed because their actions and interactions are understandably tied to their need to earn, protect, and even grow their own incomes.

Reducing the Cost of Care
In an effort to reduce costs, there are five ways commonly discussed for doing so.  Four of them are tied to changes in how services are reimbursed: 1-just lower fees in the current fee-for-service system; 2-transition to a pay-for-performance model where fees are based on quality and value of the service; 3-combining payments for distinct episodes of care (fee-bundling); and 4-creating global payment systems, such as capitation.  The fifth is to simply restrict access to, or ration, certain forms or quantities of care.

Let’s look at and compare the first two of these reimbursement methods and how they influence providers in their role in determining both the quality and cost of health care.

Fee-For-Service Reimbursement
Fee-for-service reimbursement is currently our dominant payment method.  It rewards providers for prescribing more treatment, not less, with the same financial benefit for a superior treatment outcome as for an inferior one.  An inferior one even requires more treatment, which of course can mean more income.  So the more services a provider carries out and the higher the price of those services, the more money that provider makes.

This volume-driven system creates considerable conflict for providers, many of whom understandably develop an economic bias in favor of treatments that pay better, sometimes even if they are unproven, without necessarily even considering what’s best for their patient. That widely held economic bias moves providers toward delivering as much treatment as possible, rather than providing treatment only as needed for recovery.

So to merely reduce fee-for-service reimbursement fees as a major cost-cutting strategy will only provide very short-term savings as neither patients nor providers have any incentive to reduce levels of utilization or to maximize the quality of care.  To the contrary, it is predictable from past experience that reducing those fees will only motivate more treatment to compensate for the lost income from lower fees. Since delivering high quality care is not rewarded financially, it therefore is very often not the provider’s primary objective.

Pay-For-Performance Reimbursement
Alternatively, the intent of a pay-for-performance, or value-based, system is to reward high quality and value in the care provided.  It does this in large part by eliminating providers’ conflict so their financial incentives match their patients’ priorities.  Providers are therefore rewarded for the quality of their work, not its quantity.

There are two fundamental challenges within this system however.  The first is how to accurately define and establish some standard of quality and value and then how to measure its delivery in a reliable, meaningful manner.

If Value = Quality/Cost, then value increases by improving the quality of the outcome, by decreasing the cost of care, or, ideally, both.  The current reality, especially in spine care, is that costs keep rising, rather dramatically in the case of injections and surgery, with little, if any, evidence that patients’ outcomes are improving as a result.  For all the technological innovations in spine care over the last two decades, the value of that care has actually decreased.

So what does a quality outcome look like? Ideally, it is best defined by those seeking care: the patients.  A survey of physicians, low back pain patients, many of whom were out-of-work because of their pain, treating staff members, and third-party payers (including employers) asked which of six treatment objectives they valued most.  Physicians and patients valued pain control most, while the treating staff and payers valued return-to-work the most. Fortunately, these two objectives often improve together.  In fact, pain relief and functional improvement have become fairly standard measures of quality spine care.

What is Effective Care?
There is a second challenge: there is little convincing evidence that most forms of treatment provide any higher quality and savings than others.  Many interventions remain controversial: opioid therapy, epidurals, physical therapy, chiropractic, facet blocks, discectomy, fusion, and kyphoplasty/vertebroplasty.  The evidence supporting the reimbursement for much of this care is unfortunately not convincing.

Perhaps the most important reason these treatments are so controversial is not because they are ineffective, but because we simply don’t know how to determine who will benefit from each and who will not.  Each likely has the potential to provide benefit, but only for certain patients. We just don’t know how to determine who they are.  Some researchers are working on how to best determine this.

Improving Health Care Requires Innovation in Patient Assessment and Classification
As long as we continue to reimburse health care using a fee-for-service, i.e. volume-driven, reimbursement system, we will not substantially improve the quality of care.  This system offers providers no incentive to improve their outcomes nor to find innovative ways to select patients better.  Who cares if the patient will benefit or not, if reimbursement is the same either way?

We must first learn how to make better treatment decisions but, again, there’s no incentive to develop that know-how or innovation until there’s some financial reward for doing so.  The greatest financial reward targets high-priced invasive treatments rather than innovation in how to excel in patient selection for those procedures.  So both quality care and innovation are stifled by fee-for-service.  Regina Herzlinger writes: “it’s only innovation that’s going to control our health care costs: innovation is insurance, in the way health care is delivered and in technology.”  Meanwhile, Clayton Christiansen, in his book “Innovative Prescription”, describes fee-for-service reimbursement as a “perverse regulator” of health care and a strong deterrent to innovation.  Innovation is a key component of health care progress and volume-based reimbursement is obstructing its development.  He also predicts that diagnostic innovation will become the higher paying form of care.

Despite these challenges, both the quality and cost of care can be improved when treatments are provided that predictably deliver sufficient benefit that the patient needs no further care AND is able to function well, long-term, so no, or very little, care is needed again.

It is the availability of high quality, low cost care for back, neck and musculoskeletal pain that SelfCare First wants to bring to the attention of everyone dealing with these conditions: patients, providers, employers, health plans, and even researchers. The data being generated by health plans and employers in terms of cost-savings, both short- and long-term, for the use of MDT is very impressive. You can read more about this in my other blog postings and at our SelfCare First website.

Please visit us and let us know how we can help you, via email or leave your comment or question below.

Dr. Ron

Ronald Donelson, MD, MS

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

SelfCare First, LLC
Blog: blog.selfcarefirst.com

In a prior blog, I reported that most individuals struggling or disabled by low back or neck pain actually have a condition that is rapidly reversible. That means that, regardless of how long they’ve had their pain, if it’s rapidly reversible, and it usually is, it can still be turned around and corrected, providing the proper type of evaluation and treatment is undertaken.

This is very exciting news for two different very large groups. The first and obvious one is comprised of those who are personally experiencing pain in their back or neck and trying to endure all the day-to-day consequences of it. There are millions of you out there.

When you seek care, you are so often prescribed unproven and questionably effective treatments that are typically based on your clinician’s theories or favorite type of care. When your pain and impairment persist, some of you understandably turn to “alternative care” methods, most of which have even less scientific basis. With further failure to recover, you understandably seek spinal imaging (CT scans and MRIs), injections, and even surgery.  Some of you are even rushed to expensive, painful, even risky procedures within days of the onset of your symptoms, justified by the intensity of your pain, your high level of impairment, and the hope the surgeon offers of returning to normal quickly.

But there is a second group that also suffers, but in quite a different way.  Your suffering is primarily economic.  You are the employers who often tremble as you watch your employees with back or neck pain go off to consult with one of a wide assortment of clinicians in your community who prescribe an equally wide array of treatments. Some employees recover quickly, often on their own, but many do so very slowly and often only partially, while others simply do not recover. Most of you, along with your risk managers, see some clinicians be more effective and caring than others but usually with limited predictability of a successful recovery.  Some treatments may even stretch your sense of appropriateness.  Despite your best efforts to control them, your costs for these spine disorders have been steadily increasing, in fact skyrocketing, over the past 10 years with no evidence you are purchasing any better quality of care for all you’re spending.

There are two other prominent stakeholders that are also discussed at length in my book Rapidly Reversible Low Back Pain. They are the clinicians who care for these disorders and the spine researchers who investigate them. Neither of these groups directly suffer from either the physical or economic pain.  In fact, they both make their living on the existence and even persistence of back and neck pain.

So it is the patients and their employers who directly suffer and have most at stake in finding a solution.

However, the good news for members of all four groups who sincerely seek cost-effective solutions is that significant progress is being made. There is considerable data clearly showing that most LBP is rapidly reversible and that costs can be cut dramatically by identifying those individuals early in their care.  In a properly incentivized world, there should be widespread clamoring for this knowledge by all stakeholders.

So how do these various groups objectively determine who has and does not  have rapidly reversible back or neck pain? Concise and evidence-based answers are now available in the scientific literature and are the focus of my two books entitled “Rapidly Reversible LBPand “Solving the Mystery. Please take a few minutes to read the Foreword and well as a few published book reviews for RRLBP.

It remains my hope that these books will be catalysts for progress in bringing more understanding and know-how to our management of back and neck pain.

Dr. Ron

Ronald Donelson, MD, MS

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

As I pointed out at the end of my Nov. 23 blog, as an employer, you are no doubt suffering badly from the very high costs of care for low back and neck pain, in fact from all musculoskeletal disorders.  In the health care marketplace, you are at such a disadvantage, with very little control over your costs, primarily because no one is telling you the truth about the current state of care for these disorders.

Today, I want to cover some very cost-relevant information: things you don’t know that are costing you money, and then some very encouraging news.


  1. The so-called natural history of recovery from low back or neck pain (recovery independent or regardless of any formal care) is simply not reliable in helping your employees recover.  I will discuss this very point in greater detail in an upcoming blog.  Many studies show that 60-70% still have pain a year later, or have one or more recurrences. Recurrences often progressively worsen until episodes no longer recover and pain then becomes chronic.  That means it no longer stops; no more pain-free intervals.
  2. Conventional office evaluations and our most advanced imaging techniques do not provide a confident diagnosis in most cases of low back and neck pain. Many who are having NO pain actually have herniated and/or degenerated discs if they undergo an MRI.  MRIs can therefore actually be misleading, causing inappropriate treatment, including surgery, based on the appearance of “abnormal” discs that are not even the cause of the pain.
  3. Consequently, most clinicians choose their treatment based on their training background and favorite treatment(s), NOT on what is causing your employee’s pain.
  4. Further, there is no standard treatment for low back or neck pain.  What treatment your employee receives is determined by what office (s)he walks into, not on what is actually causing the pain.
  5. Most treatments are therefore minimally effective. Some are even detrimental, especially if they take up valuable time (weeks, even months) when your employee could be recovering with care that targets their specific disorder.
  6. A separate but strongly related issue: the current system of paying clinicians rewards them for lots of care (high volume) and not for its quality. Naturally, many clinicians select treatments that either pay well or need to be repeated.
  7. Some insurance and workers compensation plans know this information but are so focused on their own needs and bottom line, they’re reluctant, or too busy with other matters, to bring this information to their employer-customers.


  1. Using new clinical examination methods, a far more precise diagnosis can now be made for your employee that guides treatment decisions that produce highly effective, predictable recoveries.
  2. Consequently, 80-90% of back and neck pain can now fully recover inexpensively, quickly, and easily by determining the most effective treatment for each individual.
  3. These same methods also teach your employees how to prevent the next episode.  Recurrences over the next year can be reduced from 60-70% to 10%!  And that’s so predictable that some clinicians who use these methods well are “guaranteeing” their results.
  4. Even for those employees who were never initially provided the opportunity to be evaluated, if they reach the point of having spine surgery recommended and if these same evaluation methods are then introduced, three studies report that at least 50% can still be rescued from undergoing surgery, most with a quick, often fairly easy, and complete recovery.  These patients commonly state: “Why hasn’t someone shown me this before?” or “I can’t believe it’s this easy.”
  5. Rather than financially rewarding clinicians for their volume of care, rewarding clinicians’ performance greatly motivates high quality care while substantially lowering the overall cost of care.
  6. Actively addressing all these factors has been shown to save employers 50% in both their direct medical and all indirect costs.

Please visit www.selfcarefirst.com for more detailed information and the opportunity to sit in on a live webinar specifically for employers wanting to gain control of their spending on musculoskeletal care.  I’ll be talking more about this in future blogs as well.

Dr. Ron

Ronald Donelson, MD, MS

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

SelfCare First, LLC
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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