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.

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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
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

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

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