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Thurst Manipulation of the Cervical Spine: To Do or Not to Do

There has been some recent email traffic amongst a close group of colleagues on this article recently published in JOSPT. You can read the study for yourself, but the gist is that the combination of upper cervical and upper thoracic high velocity thrust manipulation was more effective in the short term (48 hours) than nonthrust mobilization in patients with mechanical neck pain. The question centers around whether and/or how to incorporate this evidence into practice. Rather than offering a summary of the comments, I thought it would be helpful to simply paste the comments verbatim and then open it up for a conversation on the blog. I did do some editorial clean up of syntax, grammar, etc. I left names off because I didn’t get permission to include their comments. However, these are each thought leaders in their own right who generally don’t mind expressing themselves so I am taking a risk that they won’t mind. I did remove comments that could be linked back to a specific individual. Other than these exceptions, the comments are verbatim.

Comment 1
This is an area that I have struggled with for years. Currently I do not teach upper cervical manipulation to the entry level students. I have taught upper cervical manip to entry level students in the past, but I don't think they can control their hands enough to do it safely. Now one could argue that the manip James Dunning used in this study might be safer than some of the other upper cervical manips that involve rotation (ala Gibbons and Tehan), but I still don't think entry level students can learn this properly in the time we have to teach it. I do teach middle and lower cervical manipulations and they do ok with it. I do not think upper cervical spine manipulation is an entry level skill, and, one could argue, that cervical manipulation in general should not be taught until there is more evidence. I do use upper cervical manipulation a lot in my patient care and find it extremely useful, but I treat a young, healthy population (college students) and do a lot of screening.

Comment 2
I don't have much to add except that it would be interesting to see what the longer term outcome looked like. I am curious why they didn't report at least a discharge time frame outcome like 4-6 weeks. Obviously even longer term would be better. Presuming there are no differences at 4-6 weeks, I am not sure the outcome is worth even a small risk (real or perceived), especially if some of the patients were acute, the stage in which a stroke might naturally occur regardless of a manipulative intervention.

Comment 3
I don’t have a lot more to say but agree that the students don’t have enough feel or clinical knowledge to perform upper cervical manips. I certainly don’t teach it to them. They can do very well using MET and Mobs. Actually, even though the study in question uses cervical manips, there are others out that say mobs and manips are of similar benefit in the cervical spine. So, again the discussion of risk benefit is appropriate. I won’t shy away from having the students read the article, but I don’t think that is what I would want to project. A healthy discussion following is a good idea.

Comment 4
Agree with the only clarification being that upper cervical manip is a motor skill that can be learned by entry-level students if there were enough time and there was a definitive benefit that justified the resources for packing it in and teaching it. Given the current structure there isn't. That having been said, it very well may be that this is something Interns can learn after they have been in the clinic for a while, performance has been assessed, and the CI can give adequate time to teaching this to Interns who would have developed more skilled hands. I think we just need to be consistent in our philosophy about teaching manipulation. It isn't about 1st professional or "experienced" (there are a lot of those I wouldn't teach either). It’s about time, resources, and priorities based on evidence (harm/benefit).

Comment 5
Framing this is important.

1. I do not specifically teach thrust manipulation of the upper cervical spine to entry level nor do I advocate it for post professional at least without a serious dose of respect to this area.

2. As evidence emerges, this may change. So, it is in within the scope of practice of entry level PT as are PNF techniques. However, a student may or may not learn all the PNF or manipulative skills. So we need to be very clear that it is within the scope but caution is warranted.

3. I treat an older population and am less nervous about them in terms of a VBI stroke (carotid different picture). I actually am much more cautious in our student labs because that group is at higher risk for a VBI stroke than my crusty old folks. Now I am more aware of BP, HR, overall stroke risk, etc in my older adults but much more concerned about treating younger adults, particularly “loose neck” females.

Hopefully this is enough to get a decent conversation going on the blog regarding whether you agree or disagree. Before commenting, do try and review at lease the abstract of the study as it will likely help inform your thoughts and comments. Hope everyone has a great weekend!

John

Spinal Fusion Rates Continue to Climb

This article from Medscape came across my radar a few days ago, and a number of colleagues had some interesting email dialogue around it (Britt, thanks for initiating the discussion!). The gist of the conclusion is that between 1998 and 2008, the annual number of spinal fusion discharges increased 2.4-fold (137%) from 174,223 to 413,171. In contrast, during the same time period, laminectomy, hip replacement, knee arthroplasty, and percutaneous coronary angioplasty yielded relative increases of only 11.3%, 49.1%, 126.8%, and 38.8% in discharges, while coronary artery bypass graft (CABG) experienced a decrease of 40.1%.

A few points worth considering. First of all, TKA is a close second in growth rate, so clearly there are other surgical procedures that might rival spinal fusion surgery for the “over utilization of the year” award. It would also be interesting to know the percentage growth of spine surgeons compared to other specialties during this same period. In other words, is the rate of increased utilization commensurate with the rate of training spine surgeons? What is definitely clear is that the increased utilization of spine fusion is not commensurate with increasing evidence to support it because none (or very little) exists, especially for chronic pain, which is unfortunately an all too common indication being used to justify doing the procedure.

If you remember our infamous “Whore of the Month” series from a few years ago (George, no worries…we won’t bring it back!), I am afraid spine surgeons (not all of them but certainly the ones doing lots of unnecessary fusion surgeries) might be our first lifetime member because of the frequency with which “bad news” emerges with respect to spine fusion.

I suppose that for the sake of patients with chronic back pain looking for a cure (and willing to be exposed to high risk procedures that offer very little hope for benefit), we can only hope that spinal fusion surgery might soon go the way of coronary artery bypass graft, which is down! As Barb Stevens said in our email dialogue, we should expect to see PT become the safer, less expensive, and more effective alternative to spine surgery just as stents have been to CABG.

What say you?

John

A Blast from the Past

I received this interesting email below from Richard Don Tigny, whose views on the SI joint bring back memories of the 1980s and 90s...way out of touch with reality. Nevertheless, I thought his comments were instructive on a couple of points. First, if we are to become an evidence-based profession, we have to learn to respond in a timeframe faster than 5-6 years. He is apparently responding to some critical comments I made back in 2007 regarding his views being inconsistent with current evidence (view which are even further away still in 2012).

Also, before you criticize me for posting what was intended as a private email on a blog, I did ask for and receive his permission to post his comments here, which brings me to my second point. Some individuals don't mind sharing their lunacy with the entire world, which reminds me of a quote by Epictetus who said, "We have two ears and one mouth so that we can listen twice as much as we speak." In all seriousness, and with no intent to make this a personal attack, it's helpful to realize that there are a few who still cling to views that are completely out of step with current best evidence. Although I hesitated to even post his viewpoints because doing so might give them more credibility than they're worth, it's sometimes instructive to see a stark contrast of what EBP is not to help determine the way forward as this represents a known point from which we can run clearly in the other direction. The below example is the epitome of times gone by in PT and hopefully a place we will never return.

Richard and others are certainly free to disagree (and I can count on an email from him shortly I suspect as to why I am wrong), but trying to convince someone that the SI joint moves in a clinically meaningful way is not a defensible position.

John

Email from Richard Don Tigny

HI John,
I just ran across you 2007 comments regarding my research.
Just thought I would bring you up to date on my more recent observations.
Pelvic dynamics have been essentially ignored for many years because it has been assumed that they were far too complex for anyone to analyze and because an early researcher reported essentially no movement in the sacroiliac joint. In 1965, I saw a patient who had recovered immediately from common low back pain through a fortuitous accident and I realized her pain was caused by a reversible, biomechanical lesion. Through the succeeding 45 years I have been able to successfully analyze these pelvic dynamics. Others probably could have done this in much less time, but none have chosen to do so.

Among some of the various items that I have uncovered are:
1. A bony transverse loading axis of the sacrum posterior to the S3 SIJ segment, verified by Gracovetsky.
2. Form and force closure ( Vleeming) only occur in the unloaded pelvis or in the cadaver pelvis. After the sacrum is loaded and the pelvis is symmetrical, a system of balanced ligaments causes a net 0 closing force at the sacroiliac joint.
3. The sacrum hangs from the posterior interosseous ligaments and the sacroiliac joint (SIJ) is essentially a non-weight bearing joint.
4. When the pelvis moves into asymmetry during normal gait, the innominate on the side of loading rotates caudad on an axis through the pubic symphysis and moves the sacrum caudad, but does not move caudad on the sacrum.
5. When the pelvis is asymmetrical the sacrum flexes laterally in the long straddle position to create an oblique sacral axis.
6. The sacrum moves on that oblique axis to drive counter rotation of the trunk in order to decrease loading on that side. This has a major effect on normal gait.
7. There are two prime movers of the sacroiliac joint, the piriformis and the sacral origin of the gluteus maximus, which function to restore pelvic symmetry at mid-step.
8. A biomechanical vulnerability of the pelvis to injury through minor trauma occurs with anterior rotation of the innominates on the sacrum and a loosening of the sacrotuberous ligament.
9. A shift in the line of gravity anterior to the acetabula disturbs the ligamentous balance and allows the innominates to move cephalad and laterally on the sacrum at S3 to subluxate and fixate. This is the cause of acute idiopathic low back pain with or without a non-disc sciatica.
10. The ilial tuberosities function to prevent any posterior functional or dysfunctional movement of the innominate on the sacrum.
11. Posterior rotation of the innominates on the sacrum and upslips are clinically insignificant, occurring at the S1 SIJ segment.
12. The dysfunction in anterior rotation causes a vertical shear on the conjoint origins of the gluteus maximus and the piriformis at the S3 SIJ segment, which is the cause of the piriformis syndrome.
13. The dysfunction in anterior rotation increases the lumbosacral angle and loosens the iliolumbar ligaments and increases shear on the lower lumbar discs. This may initiate a spondylolisthesis and is probably the cause of disc disease.
14. The dysfunction in anterior rotation may cause a reversible, biomechanical asymmetry of the pelvis with a reversible change in leg length.
15. Pain in the abdomen at Baer’s sacroiliac point is not uncommon with SIJD and is commonly the cause of unnecessary surgery. This point is on a line from the umbilicus to the anterior superior iliac spine, two inches from the umbilicus and pain there is relieved with corrections or injections to the SIJ.
16. It is possible to make a diagnosis of the dysfunction of the SIJ in anterior rotation merely by identifying a painful point at the posterior inferior iliac spine.
17. The conventional side-lying treatment of this dysfunction by chiropractors and physical therapists will eventually cause the long posterior ligaments to become unstable and is probably now the chief cause of chronic low back pain.
18. Increased loading of the femoral head from a non-functioning SIJ may cause microfractures in the subchondral bone with roughening of the joint surface and eventual arthritic changes.
19. Dysfunction of the SIJ in anterior rotation loosens the muscles and ligaments of the pelvic floor and correction to the balanced position tightens the pelvic floor.
20. Sturesson made a procedural error in his measurements of the SIJ and wound up measuring a symmetrical pelvis in the long straddle position. Smidt was correct. See x-rays at www.thelowback.com .
Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints. A roentgen stereophoto-grametric analysis. Spine 14:162-165, 1989
. Smidt GS, McQuade K, Wei SH, Barakatt E: Sacroiliac kinematics for reciprocal stride positions. Spine 20(9):1047-1054, 1995
DonTigny RL: Sacroiliac 101: Form and Function - A Biomechanical Study. J of Prolotherapy, 3(1): 561-567, 2011
21. With full correction of the dysfunction of the SIJ in anterior rotation, at least 85-90% of all patients will be essentially free of pain within about ten minutes.
X-ray evidence of SIJ movement is on my website as well as many illustrations of pelvic dynamics.
I invite you and your colleagues to visit at www.thelowback.com, How it works, why it hurts and how to fix it. My bibliography is also on that website. I also have a CD for professionals with over 650 slides and 150 illustrations.

#Physical Therapist Value Stream. We are Force Multipliers

We interrupt my series on Physical Therapist Pet Peeves to bring you some excellent data from Health Affairs Sept edition on Virginia Mason, Collaboration Among Providers, Employers, And Health Plans to Transform Care Cut Costs And Improve Quality (abstract only, full text for subscribers only).

EIM blog reported to the  physical therapist community on the day of publication the now widely distributed WSJ article on Virginia Mason's novel efforts to wean itself off pricey tests through the use of Physical Therapists (not physical therapy!) as front line patient access points.  It has been our belief for some time that physical therapists are truly force multipliers that achieve cost effectiveness and outcome through the consistent adherence of EBP for low back pain.  (another example is here).  There is also no question that downstream costs in imaging, pharmacy, and surgery can be realized by greater utilization of physical therapists. Fortunately, as the Health Affairs Article points out, we now have empirical evidence.

The article details the importance of the collaborative process in getting groups of providers to agree on defined clinical pathways for high cost drivers resulting in a "value stream".  Virginia Mason's group defines quality in terms of access, high patient satisfaction, rapid return of functioning and the use of evidence based care at an affordable price.  While we often think of EBP in terms of our own profession, the most critical point of agreement amongst collaborators is that EBP be based on a particular clinical question as opposed to the expertise of a single practitioner.  The majority of providers participating in the clinical value stream complete full course in EBP and their belief is that the first office visit where the appropriate treatment is determined and initiated is the most important step.  For low back pain, this is the job of physical therapists.

While much of the article points out the significant savings in value stream headache by avoiding over utilized MRI's in the diagnosis, LBP is given ample coverage.  Rapid access to care is deemed critical in achieving correct care AND savings.  From the article:

For our back pain value stream, the use of physical therapists to perform some functions previously assigned to physicians improved Virginia Mason’s financial performance by increasing the number of patients seen and making more efficient use of physician time. Under the back pain value stream, we were able to accommodate 2,300 new patients per year, compared to 1,404 under the old system, in the same physical space. The physicians also became more efficient under the new system, with an average billing of 58.3 relative value units per day compared to 28.1 relative value units per day under the old system. Relative value units are the basis for physician payment under fee-for- service, so they represent an estimate of revenue generated.

Costs to the employers were decreased through the elimination of unnecessary imaging tests and fewer patient visits to providers. In addition, rapid access to care and increased efficiency of care delivery contributed to more rapid return to work. Postvisit surveys of patients seen in our back pain collaborative value stream revealed that patients in this collaborative required fewer physical therapy visits and fewer lost work days than local averages (4.4 compared to 8.8 and 4.3 compared to 9.0 for physical therapy visits and lost work days, respectively)

Perhaps even more indicting on cost elements is the dollar assessments of providers:

Providing the services of an orthopedic surgeon or other procedural specialist costs approximately $4 per minute. A generalist physician whose practice consists predominantly of patient evaluation and management, rather than performing procedures, costs Virginia Mason $2 per minute. A nurse practitioner or physical therapist costs $1 per minute or less.

Acuity is likely a factor in the decreased number of visits vs. local averages which supports early and direct referral to physical therapists.  While there are advantages to organizations of a vertically oriented system like Virginia Mason, it is not a difficult task for a payor to direct care on low back pain to physical therapists. This should be the standard.

We will likely continue to pile up evidence that PT's are the force multipliers in healthcare. We now have to actively advocate for appropriate changes to make it happen.

Thoughts?

larry@physicaltherapist.com

"The Reports of My Death are Greatly Exaggerated....."

The Oxford debate and post yesterday realated to it have created quite a stir and some good discussion. Obviously, none of this has occurred in a vacuum.  Around 2000 we begin to see CPRs reported in journals targeted toward physical therapists and subsequently numerous studies of this kind, most developmental with much fewer validation studies.  There has even been a book published this year by Glynn and Weisbach specifically dealing with CPRs and application in physical therapist practice

We have also more recently seen criticisms related to the CPR research methodology and subsequent application of the findings from these studies, complete with editorials and studies whose underlying purpose appears to be to discredit the approach……even an Oxford debate on the issue.

However, let’s make one thing clear: despite their stage of evolution related to physical therapy practice, clinical prediction rules (or perhaps better termed “guides”) are a recognized domain of practice and, as pointed out in some of the comments to yesterdays post, have proven to be of great value in other areas of health care. 

Go ahead link to the Clinical Queries feature on PubMed and take a look at the drop down menu. You will find there, in the following order, these options:  Etiology, Diagnosis, Therapy, Prognosis, and Clinical Prediction guides. 

 

 Tim Richardson was right- the question of “Clinical Prediction Rules, Dead or Alive?” was one that should have never been framed.  For those that disagree, why not suggest “Therapy Trials, Dead or Alive?” for next years debate (it is on the same list that Clinical Prediction guides is on so simply take your pick).  The question isn’t whether they are a valuable tool and domain of practice, they undisputably are. The real question is how do we best develop and validate CPRs in order to help quantify clinical decision making and allow for more a more informed clinical reasoning process in the care of our patients.

 As Mark Twain once said and that can be said figuratively of CPR’s,  “The reports of my death are greatly exaggerated”.

 

Sincerely,

 

CPR

Measuring Quality in #PhysicalTherapy

What is quality? How do we really know we provide quality care?

The majority would probably believe using a measurement tool to capture the change that happens between two points in time is adequate. Did the patient's initial presentation change enough to indicate something really happened? If quality care isn't provided, not much change will occur, right?

I'm beginning to think measuring quality is a lot more complex than any of us originally thought. First off, if we look into the diversity in which we have a role, you'll easily see, in certain situations, we may not be able to truly measure quality. When we provide services, the person in front of us drives the process. People will choose to receive physical therapy services for probably four distinct reasons: 1) to stay healthy, 2) to get better, 3) to learn to live/cope with a disability or illness, or 4) to cope with end of life. The measurement tools readily available to us tend to focus on reason #2. What do we do in the other three situations to capture the quality or impact of our services? In those three other scenarios, I'd like to think we have an impact, yes, but... the capability to capture the impact or the quality of what we provided is difficult. As our future unfolds, how will we help mold the changes to allow for three situations where our services are needed and not pigeon-hole ourselves into regulatory requirements demanding we standardize a process to document changes in presentation for payment for services?

How about adding another factor into the complexity of using standardized tools to measure change which ultimately would be extrapolated to help prove "quality?" Take the 6 Minute Walk Test. This is a standardized, functional test measuring the distance a person is able to walk. This is a really, really easy test to implement and answers the question of how far a person is able to walk in 6 minutes. Easy to do; easy to document; easy to readily know if distance changed. The question to be answered when comparing distance results is... was the change in distance relevant? This brings us to the concept of minimal detectable change (MDC). Are MDC fixed variables? Sadly, no, they are not. More and more, it is becoming apparent that each patient population may have a designated MDC. In other words, I may want to get excited that after 4 weeks of physical therapy, my patient who has Parkinson's Disease walked 80 feet farther. I really can't get excited though because research indicates for a person with Parkinson's Disease 269 feet is the MDC. (I will admit, I do think some of the MDC are crazy... it honestly doesn't seem reasonable to have 269 feet as the distance indicating that the change in distance isn't measurement error. Have you ever walked with someone who has Parkinson's Disease? I don't quite understand how the standard error measurement can be 50-60 feet. Seriously, are we that inadept at measuring distance or hitting the start/stop stopwatch buttons?) Someone's going to need to design an app for the various outcome measures, populations and matching MDC or a really smart physical therapy based electronic health record with this kind of information built into the system and frequently updated. Seriously, look at the Berg - who's going to easily remember these details?

So, if minimal detectable change isn't your forte. For some outcome measurement tools, minimal clinically important difference is the relevant factor. How about pain? Quite a few people seeking our services report pain. If we choose to use reduction of pain as a quality indicator, it isn't as simple as we'd intuitively think. The location of pain and the onset of pain are factors to be considered when interpreting change in pain. The duration of the episode of care might even need to be considered. So, again, another example of a measure not having a fixed score that readily indicates clinical change occurred.

And now... now we have a fairly new concept to enter into the mix of complexity - minimally clinically important improvement (MCII). In 2007, French biostatistians and/or rheumatologists (not sure which) introduced the concepts of MCII and patient acceptable symptomatic state (PASS). In a nutshell, these two concepts bring the patient's opinion into the picture too - in other words, a stand alone outcome tool measurement score was kind of meshed with the patient's perception of improvement. That's probably a good idea because there are times I have patients indicating to me improvement yet the outcome tool doesn't have a large enough change in score to be clinically relevant. MCII was recently introduced in physical therapy literature by the statistical, superstar, number crunchers associated with Focus on Therapeutic Outcomes. Meshing a Global Rating of Change (GROC) with the FOTO Functional Status (FS) score creates huge complexities in attempting to use the results to prove quality. Significant differences in MCII were noted in various groups of patients who: 1) had really low intake FS scores, 2) were males, 3) had an onset of symptoms <22 days and 4) were 18-44 years of age. These findings again bring home reality - in order to determine change or improvement, the defining number to use isn't some fixed, consistent constant variable.

So how do we utilize all this type of evidence in the future during dialog and negotiations with outside stakeholders when they attempt to create quality reporting mechanisms and policies for reporting change... which of course will be tied to payment methodologies which include "quality of care" in the equation?

~Selena

Hip hurt? Eat More Meat!

At least according to this recent study entitled “Meat consumption and risk of primary hip and knee joint replacement due to osteoarthritis: a prospective cohort study” that was recently published in BMC Musculoskeletal Disorders. It turns out that regardless of what is happening to your cardiovascular system, there is emerging evidence for a beneficial effect of meat consumption on the musculoskeletal system.

These authors performed a prospective cohort study that included 35,331 Australians and examined the relationship between meat consumption and risk of primary hip and knee replacement for osteoarthritis as evidenced by total joint replacement of the same. They found that was a negative dose-response relationship between high levels of fresh red meat consumption and the risk of hip replacement (but not knee replacement but hey, we ardent carnivores will take what we can get).

Now we can not only feel good about having a glass of red wine, our morning coffee, and satisfying our chocolate craving, but we can also fire up the grill and offer up a toast to that mound of fresh red meat that many of us love to eat! Notice I said “feel good” because a high level of confidence that our health is necessarily better off from any of these things just isn’t there, but they do make life richer for many of us.

Isn’t it interesting what you can find in the literature? I think the only way one comes across these kind of headlines is to either: a. be so head-down buried into a certain topic that you pursue the nuances and intricacies of your particular niche topic; b. read a blog related to health issues like this one; or c. have a push-information system like Evidence Express that puts this kind of information along with other more relevant research findings directly and automatically in your mail-box on a regular basis.

Hope your weekend is good……keep your grill hot.

Rob

Family Practitioner- Who Should I See For My Back Pain?

Ok, although both orthopaedic surgeons’ and family physicians’ knowledge of treating LBP is reported to be deficient, Orthopedic surgeons are less aware of current EBP treatment approaches than family practitioners. Therefore, you decide to see a family practitioner for your recent episode of debilitating LBP

If live in Australia (and probably the US), then according to the findings of this paper by Buchbinder and colleagues, make sure you DON’T see a family practitioner who has a special interest in LBP or you are more likely to get prescribed bed-rest and imaging right of the bat. Instead, see an FP who has a special interest in musculoskeletal medicine in general or in occupational medicine (though you still may get the same ill-advised care albeit with a lower probability). This is despite the fact that all groups thought Clinical Practice Guidelines are helpful for medical conditions in general and LBP in particular.  I guess that this is probably best explained as a difference between the general “I feel you” vs actually knowing content vs actually doing comes into play.

The authors conclusions: “…we found that having a special interest in LBP was associated with back pain management beliefs that are contrary to the best available evidence”………is that an oxymoron/paradox or what!?

Well, the good (and perhaps surprising) news is that the study also found that having had CME related to LBP management resulted in more evidence-based beliefs about LBP.  Belief is obviously believing is not the same as doing, but hey, you have to sometimes take what you can get. In the meantime, I guess we simply have to continue to “pound the rock” and at the same time look for better and more effective hammers so we can get that nut cracked after the 1millionth blow vs 100 millionth blow.

Anyone know of any good hammers? Simply seeing an PT who practices in an evidence-based manner directly for your LBP is arguably the best solution but I wonder, if PTs were surveyed, how much different would our results be? It would be interesting to find out but one thing we for sure know won’t happen in that scenario is that imaging and minimally or non-effective/harmful medication won’t be prescribed and everyone still wins.

Rob

Orthopedist or Family Practitioner- Who Should I See For My Back Pain?

The article Orthopaedists' and family practitioners' knowledge of simple acute low back pain management is both informative and a great example of why one can go terribly awry simply reading an article abstract and worse yet, only the abstract conclusion. In this case, the primary abstract conclusion was: “Both orthopaedic surgeons’ and family

physicians’ knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners……”. This would elicit a “Tell me something I don’t already know” response from readers of this blog in many cases. However, when you read further you realize that this article doesn’t really provide an answer to that question.

The researchers determined knowledge deficiency in these two groups of doctors (253 orthopedists and 140 FPs) via responses to a questionnaire at their professional conferences (apparently in Israel). The 5 questions related to: 1. use of medication (paracetomol or standard NSAID vs COX-2 meds); 2. Effectiveness of bed rest; 3. Effectiveness of encouragement and advice; 4. Effectiveness of manipulation; and 5. Need for imaging studies. Physical therapy was also listed (whatever that means or includes) but was not analyzed due to conflicting recommendations.

Results? Back then, if a patient saw an Orthopod they were going to receive a lot more COX-2 Meds, X-rays, bed-rest and less encouragement than that would from a family practice doc. Interestingly, more than half of both Orthopods and FPs viewed manipulation as appropriate but that was graded as an inappropriate response by the researchers. Physical therapy: well, what’s that? (ok, we can’t figure it our either so let’ not count that answer.)

A few things to consider: The answers were based on a 2001 Clinical Practice Guideline, the questionnaire was administered in 2005 and this article was published in 2009 (probably not exactly the best data to give us a current understanding of how these two physician groups view and manage patients with LBP).

However, there is plenty of evidence to suggest that imaging, meds and in some cases bed-rest are still frequently used. I do wonder if their perspective on the use of manipulation for acute or chronic LBP is still moderate (51% and 57% for orthopods and FP’s, respectively) or if it has increased, given the recommendations in current US and UK clinical practice guidelines. My own guess is that things haven’t changed much (except spinal surgery, especially fusion and increasingly disc replacement may now be popular, albeit ill-supported choices). How about yours?

Perhaps our patients should see a EBP physical therapist instead.

 

Rob

Another Stocking Stuffer

Dear Santa,

We love new and we love quicker, better, and faster…………all of us. It makes me wonder if that isn’t part of the reason Surgeons, who can make an exceptionally good living, do things like cozy up with device manufacturers instead of simply earning denaro the “Old Fashioned Way” and reserving their incredibly sophisticated craft for those who can truly benefit.

It made me think of an article in the NY Times earlier this fall about cortisone injections shared with me by one of our EIM Orthopaedic residents. When these became available in the late 1940’s it was all the rage for treating all kinds of “itisis” and continues to be used extensively for such conditions as well as pain associated with spine problems. This is despite evidence that although cortisone injections provides some short-term pain relief, they also resulted in a much lower rate of full recovery than simply doing nothing or undergoing physical therapy. People in these same trials also had a 63 percent higher risk of relapse and an average of four injections resulted in a 57 percent worse outcome when compared to one injection (we all know you “can’t eat just one”). I know we want relief and want it now, but at what price?

Human nature is what it is, translating evidence into practice is hard and behavior change is even harder so I won’t ask for anything in that regard. What I would ask for (maybe as a stocking stuffer?) is that the same level of scrutiny given by policy makers, CMS, and other payors to physical therapist delivered intervention and services also be given to other health care providers.

I have never been very good at math but it just seems focusing their attention and scrutiny on practioners who comprise a much larger part of the health care problem (hmmm, I mean pie) and who perform highly expensive procedures that can have devastating complications and side-effects would be a much better use of time and resources (especially when the evidence for effectiveness is lacking or minimal at best) than making sure they have hog-tied/air-sealed PTs with 8 minute rules and such when they only comprise 1% of CMS expenditures. In this case, just a little equality would be a beautiful thing.

Thanks Santa, and Merry Christmas!

Rob